Maternity Nursing Q 166

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One hour following a normal vaginal delivery, a newborn infant boy’s axillary temperature is 96° F, his lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy’s hands shake. Which intervention should the nurse implement first?

  

     A. Stimulate the infant to cry.

     B. Wrap the infant in warm blankets.

     C. Feed the infant formula.

     D. Obtain a serum glucose level.

    

    

Correct Answer: D. Obtain a serum glucose level.

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This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level.

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Option A: Stimulating the infant to cry is an intervention for a lethargic infant.

Option B: This intervention should be done based on the temperature, but first the glucose level should be obtained.

Option C: Feeding the infant with formula helps raise the blood sugar, but first, the nurse should determine the glucose level.

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