A client with type 2 diabetes mellitus delivered a fetus weighing 7 lb, 14 oz 2 hours ago. The infant's blood glucose is currently 45 mg/dL. What should the nurse do?
1. Begin an IV of 10% dextrose.
2. Document the findings in the chart.
3. Feed the baby 1 oz of formula.
4. Recheck the blood sugar in 4 hours.
2
Explanation:
1. The blood glucose of 45 mg/dL is considered a normal blood sugar reading for a neonate. No IV is needed.
2. A blood sugar of 45 mg/dL is a normal finding; documentation is an appropriate action.
3. Feeding would be appropriate if the infant's blood sugar were below 40, but this infant's reading is 45 mg/dL.
4. Infants of diabetic mothers should be fed frequently and should have their blood sugar assessed frequently. Four hours is too long a time frame.
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