34. A client, who is gravida 5, para 4, delivers an 11-pound, 4-ounce neonate at 38 weeks' gestation. The client has been noncompliant with her insulin administration for gestational diabetes and her blood sugar has been poorly controlled throughout this pregnancy. Which nursing intervention is the most important for the neonate?
. Administer a bolus of 50 grams of glucose IV.
. Begin formula feedings immediately after birth.
. Check heel stick blood sugar.
. Administer 10 units of insulin subcutaneously.
Test-Taking Tip
Remember: if a client has diabetes, the increased blood sugar in the mother triggers increased insulin production in the fetus, and the neonate will be hypoglycemic after birth. Select a data-gathering type of intervention (Answer 3) before an implementation option, even if the dosage in Answer 1 were correctly stated (which it wasn't).
Content Area: Child Health, Newborn; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Diagnostic Tests
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Answer 1 is incorrect because checking heel stick blood sugar is the first intervention. Further interventions may be necessary, but administering a bolus of 50 grams of glucose would not be the proper dosage. The correct dose is 0.20 grams of glucose/kg (i.e., 2 mL/kg) of IV 10% glucose, given over 1 to 2 minutes. Answer 2 is incorrect because checking heel stick blood sugar is the first intervention. Based on the results, formula feeding may be necessary, but not necessarily started immediately after birth. The neonate may be able to breastfeed first, depending on the blood sugar. Answer 3 is correct because checking heel stick blood sugar is the first intervention. Based on the results, further interventions may be necessary. Specific intervention will depend on the blood sugar value. Answer 4 is incorrect because neonates of clients with diabetes experience hypoglycemia, and administering insulin would make hypoglycemia worse.