A nurse is caring for a 28-week gestational age preterm newborn who was born 6 hours ago. The infant is receiving continuous positive airway pressure (CPAP) and has an umbilical arterial catheter in place. Which assessment finding requires the nurse's immediate attention?

Immediate Priority: A blood glucose of 35 mg/dL (1.9 mmol/L) in a 28-week preterm infant is a critical metabolic emergency. The operational threshold for treatment is typically a single value below 2.0 mmol/L (36 mg/dL) in the first 48 hours of life, with a target of ≥2.6 mmol/L (47 mg/dL) thereafter.

Pathophysiology: Preterm infants have limited glycogen and fat stores, immature gluconeogenesis, and high metabolic demands. The presence of an umbilical arterial catheter (UAC) and CPAP indicates significant illness, further increasing glucose utilization and the risk of neuroglycopenia.

Immediate Intervention Protocol:

• Administer an IV bolus of 2 mL/kg of 10% dextrose in water (D10W) over 1 minute.
• Initiate a continuous IV infusion of D10W at a rate of 80-100 mL/kg/day to maintain euglycemia.
• Recheck blood glucose 30 minutes after the bolus and then hourly until stable.
• If IV access is delayed, consider buccal dextrose gel (40% dextrose, 200 mg/kg) as a temporizing measure.

Ongoing Monitoring: Target a pre-feed glucose of 45-60 mg/dL. Avoid rapid fluctuations. Screen every 2-4 hours once stable. Document for signs of jitteriness, lethargy, apnea, or seizures, which indicate worsening neuroglycopenia.

Nursing Considerations: Ensure the UAC is patent and secure for blood sampling and infusion. Maintain a neutral thermal environment to reduce metabolic stress. Coordinate with the provider to adjust parenteral nutrition as the infant stabilizes.