The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention?
1. Vasoconstriction and pallor
2. Blood glucose level of 45
3. Room-temperature IV running
4. Positioned under radiant warmer
3
Rationale 1: Vasoconstriction is the first physiologic response to a lowering temperature; it causes pallor.
Rationale 2: This is an adequate blood sugar in a neonate. A level lower than 40 indicates hypoglycemic.
Rationale 3: IV fluids should be warmed prior to administration and wrapped in a blanket or other insulating material to keep them warm. Room-temperature IV fluids will increase the cold stress.
Rationale 4: Radiant warmers are used to gradually increase the neonate's temperature.
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