The nurse is caring for an infant who delivered in a car on the way to the hospital and has developed cold stress. Which finding requires immediate intervention?
1. Blood glucose level of 45
2. Vasoconstriction and pallor
3. Room temperature IV running
4. Positioned under radiant warmer
3
Explanation:
1. This is an adequate blood sugar in a neonate. Less than 40 is hypoglycemic.
2. Vasoconstriction is the first physiologic response to a lowering temperature and will cause pallor.
3. IV fluids should be warmed prior to administration and wrapped in a blanket or other insulating material to keep them warm. Room temperature IV fluids will increase the cold stress.
4. Radiant warmers are used to gradually increase the neonate's temperature.
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