A nurse is assisting in the care of a client who is at 18 weeks of gestation and reports nausea and vomiting daily that lasts throughout the day.
Which of the following findings indicates the client is experiencing a fluid imbalance?

? Rationale for Correct Answers

Hypoglycemia is defined in neonates as a blood glucose level <40–45 mg/dL. This newborn had a glucose of 35 mg/dL at 1 hour of life, with symptoms including jitteriness, abnormal cry, and hypotonia—all classic signs of hypoglycemia. After breastfeeding, the glucose level rose to 50 mg/dL, and symptoms resolved, confirming the diagnosis and effectiveness of feeding.

Breastfeeding the newborn immediately is the first-line intervention for asymptomatic or mildly symptomatic hypoglycemia. Early feeding provides glucose and stimulates endogenous glucose production. The American Academy of Pediatrics recommends feeding as the initial management for glucose levels between 25–40 mg/dL in asymptomatic term infants.

❌ Rationale for Incorrect Response 1 Options

Neonatal abstinence syndrome (NAS) typically presents after 24–72 hours post-birth, not within the first hour. There is no maternal history of opioid use or signs such as hypertonia or high-pitched cry.

Sepsis may present with temperature instability, lethargy, or respiratory distress, but this newborn is alert, afebrile, and has stable vitals. No risk factors or signs support this diagnosis.

Respiratory distress would involve tachypnea, nasal flaring, or retractions. This newborn has even, unlabored respirations and a normal respiratory rate of 45/min.

❌ Rationale for Incorrect Response 2 Options

Administer morphine per protocol is appropriate for NAS, not hypoglycemia. There is no indication of opioid withdrawal.

Start oxygen therapy is indicated for respiratory distress or hypoxia, neither of which is present here.

Perform blood cultures is appropriate for suspected sepsis, but there are no signs of infection or systemic illness in this newborn.

? Take-Home Points

• Neonatal hypoglycemia is common in large-for-gestational-age infants and presents early with jitteriness and hypotonia.
• First-line treatment for mild hypoglycemia is immediate feeding, preferably breastfeeding.
• Hypoglycemia must be differentiated from NAS, sepsis, and respiratory distress based on timing, maternal history, and clinical signs.
• Monitoring glucose response to feeding helps confirm hypoglycemia and guides further management.

Choice A rationale

Chicken breast is a rich source of heme iron, which is highly bioavailable and easily absorbed by the body. During pregnancy, the increased maternal blood volume and fetal erythropoiesis significantly increase the demand for iron to support hemoglobin synthesis. Consuming iron-rich animal protein like chicken helps prevent iron-deficiency anemia, a common complication of gestation.

Choice B rationale

Carrots are a good source of beta-carotene, a precursor to vitamin A, and other vitamins and minerals. However, they are not a significant source of dietary iron. While a healthy part of a balanced diet, carrots would not be recommended as the best source for a client needing increased iron intake during pregnancy.

Choice C rationale

Feta cheese is a dairy product that is a good source of calcium and protein. However, dairy products generally contain minimal amounts of iron, and the calcium in dairy can actually inhibit the absorption of non-heme iron from other food sources if consumed simultaneously. Therefore, feta cheese is not an optimal choice for increasing iron intake.

Choice D rationale

Apples are a good source of dietary fiber and vitamin C, which can enhance the absorption of non-heme iron when consumed concurrently with iron-rich plant foods. However, apples themselves contain very little iron. Thus, while beneficial for overall nutrition, apples are not a primary source of iron for a client requiring increased intake.