Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority?
a. Notify the clinician stat.
b. Test for the blood glucose level.
c. Start an intravenous line with D5W.
d. Document the event in the nurses' notes.
ANS: B
These symptoms are signs of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain, but it is not common practice to give intravenous glucose to a newborn. Feeding the infant is preferable because the formula or breast milk will last longer. Determine the blood glucose level according to agency policy, treat symptoms with standing orders protocol, and notify the physician with the results. Documentation can wait until the infant has been tested and treated if a problem is present.
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