An infant at 36 weeks' gestation was just delivered; included in the protocol for a preterm infant is an initial blood glucose assessment. The nurse obtains the blood and the reading is 58 mg/dL. What is the priority nursing action based on this reading?
a. Document the finding in the newborn's chart.
b. Double-wrap the newborn under a warming unit.
c. Feed the newborn a 10% dextrose solution.
d. Notify the neonatal intensive care unit (NICU) of the pending admission.
ANS: A
In the term infant, glucose levels should be 40 to 60 mg/dL on the first day and 50 to 90 mg/dL thereafter. There is no general consensus about the level of blood glucose that defines hypoglycemia, but a level below 40 to 45 mg/dL in the term infant is often used. If an infant is placed in a warming unit, the skin needs to be exposed. Because the glucose level is normal, no supplemental feeding is necessary. Dextrose solution is only administered when the glucose levels are very low. There is no information in the stem indicating the need for admission to the NICU.
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