the nurses assessment of a preterm infant rev...
the nurses assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. which intervention should the nurse implement first? a. assess the infants blood glucose level. b. nipple feed 1oz 5% glucose in water. c. place the infant in a side - lying position. d. position a radiant warmer over the crib.
Answer
# Brief Explanations:
Decreased muscle tone, respiratory difficulty, irritability, and mottled, cool skin in a preterm - infant can be signs of hypoglycemia. Assessing the blood glucose level is the first step to determine if hypoglycemia is present before implementing other interventions like feeding or adjusting the environment. Feeding without knowing the glucose level may not be appropriate, and positioning for respiration or warmth is secondary to assessing glucose.
# Answer:
A. Assess the infant's blood glucose level.