The nurse assesses a male newborn with axillary temperature 95.1 F, heart rate 136 bpm, and respiratory rate 48 breaths/min. Based on these findings, which action should the nurse take first?

• A. Check the infant's arterial blood gases.
• B. Notify the pediatrician of the infant's vital signs.
• C. Assess the infant's blood glucose level.
• D. Encourage the infant to take the breast or sugar water.

Answer: (C)

Cold stress in a newborn can rapidly deplete glucose stores, so the most urgent step is to determine whether hypoglycemia is present. A very low axillary temperature signals potential energy deficiency, and hypoglycemia is a common, treatable cause of this instability. Checking the infant’s blood glucose level gives the critical information needed to guide immediate management—if glucose is low, the next move is feeding if possible or initiating IV dextrose per protocol and rechecking. If glucose is normal, you can continue close monitoring and warmth while evaluating other potential causes. Other actions, like obtaining arterial blood gases or contacting the pediatrician, are important but not the first action; feeding or giving glucose should be guided by the glucose result, and giving sugar water is not the preferred first step in a neonate.