Page 839 - Saunders Comprehensive Review For NCLEX-RN

C. Interventions
1. Monitor for signs of respiratory distress, birth trauma,
and congenital anomalies.
2. Monitor bilirubin and blood glucose levels.
3. Monitor weight.
4. Feed the newborn soon after birth with breast milk or
formula as prescribed.
5. Administer glucose intravenously to treat
hypoglycemia if necessary and as prescribed.
6. Monitor for edema.
7. Monitor for respiratory distress, tremors, or seizures.

XXVI. Hypoglycemia

A. Description
1. Hypoglycemia is an abnormally low level of glucose in
the blood (< 45 mg/dL [< 2.5 mmol/L]).
2. Normal blood glucose reference interval is 45 to 60
mg/dL (2.5 to 3.4 mmol/L) in a 1-day-old newborn
and 50 to 90 mg/dL (2.9 to 5.1 mmol/L) in a newborn
older than 1 day (institutional values for normal
newborn blood glucose levels vary).
B. Assessment
1. Increased respiratory rate
2. Twitching, nervousness, or tremors
3. Unstable temperature
4. Lethargy, apnea, seizures, cyanosis
C. Interventions
1. Prevent low blood glucose level through early
feedings.
2. Administer formula orally or glucose intravenously as
prescribed.
3. Monitor blood glucose levels as prescribed.
4. Monitor for feeding problems.
5. Monitor for apneic periods.
6. Assess for shrill or intermittent cries.
7. Evaluate lethargy and poor muscle tone.
XXVII. Hypothyroidism
A. Description: Hypothyroidism is a decrease in the production of
thyroid hormone.
B. Assessment
1. Protruding or thick tongue
2. Dull look; swollen face
3. Decreased muscle tone
4. Laboratory results reveal low thyroid production
C. Interventions: Focus on thyroid replacement
XXVIII. Relief of Choking in an Infant
A. Description: Choking is also known as foreign body airway
obstruction (FBAO).

839