Which newborn assessment finding requires the nurse to take an action?
a. Glucose level of 40 mg/dL
b. Axillary temperature of 37° C (98.6° F)
c. Mild yellow tinge to skin at 32 hours of age
d. Mild inflammation of conjunctiva after eye prophylaxis
ANS: A
A glucose level of 40 mg/dL requires an action. Follow agency policy and health care provider orders regarding feeding infants with low glucose levels. A common practice is to feed the newborn if the glucose screening shows a level of 40 to 45 mg/dL or less to prevent further depletion of glucose. Infants with severe hypoglycemia may need intravenous feedings to provide glucose rapidly. A normal temperature for a newborn is 36.5° to 37.5° C (97.7° to 99.5° F). Mild jaundice at 32 hours of age is physiologic jaundice and does not need an action by the nurse, just further monitoring. Some infants develop a mild inflammation a few hours after prophylactic eye treatment.
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