A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago. The infant's blood sugar is 47 mg/dl. The best nursing action is to:
1. Recheck the blood sugar in 4 hours.
2. Begin an IV of 10% dextrose.
3. Feed the baby 1 ounce of formula.
4. Document the findings in the chart.
4
Rationale 1: Infants of diabetic mothers should be fed frequently, and should have their blood sugar assessed frequently. Four hours is too long a time frame.
Rationale 2: A blood sugar reading of 47 mg/dl is considered normal for a neonate. No IV is needed.
Rationale 3: Feeding would be appropriate if the infant's blood sugar were below 45 mg/dl, but this infant's reading is 47.
Rationale 4: A blood sugar level of 47 mg/dl is a normal finding; documentation is an appropriate action.
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