A premature infant was delivered after a prolonged labor with rupture of the maternal membranes >18 hours. The infant's weight is 6 lb, 1 oz (2.75 kg). What assessment finding would require the nurse to intervene immediately?
A.
Blood pressure reading of 60/35 mm Hg
B.
Skin temperature reading of 96.8 °F (36 °C)
C.
Unconjugated bilirubin level of 1.0 mg/dL
D.
White blood cell count of 12,500/mm3
ANS: B
This infant is at risk for neonatal sepsis. Signs of this condition include hyperthermia or hypothermia, lethargy, hypoglycemia, and poor feeding. This child's skin temperature reading is below normal, requiring the nurse to intervene. The blood pressure reading is normal for a child of this weight. The two laboratory values are also normal.
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