An infant born to a client with type 2 diabetes mellitus is lethargic, has a high-pitched cry, and has an initial plasma glucose level of 19 mg/dL. What should the nurse do immediately?
1. Have the mother breastfeed the infant.
2. Start an IV with D5W dextrose solution.
3. Start an IV with D10W dextrose solution.
4. Wait 30 minutes and retest plasma glucose levels.
3
Explanation:
1. This is an appropriate nursing action if the infant's plasma glucose levels are between 25 and 40 mg/dL. This infant needs more aggressive treatment.
2. D5W dextrose is primarily use to either prevent hypoglycemia or titrate down the concentration of administered glucose when the infant is transitioning off the glucose. A higher concentration of glucose is required for severely hypoglycemic infants.
3. This is the proper nursing action. Infants with severe hypoglycemia should be aggressively treated with IV infusion of D10W dextrose.
4. This infant is suffering from severe hypoglycemia. Aggressive treatment with D10W dextrose by IV is recommended.
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