A nurse is transporting a newborn to their parents from the nursery.
Which of the following actions should the nurse perform to confirm the newborn's identity?

? 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

Vaginal fluid with a pH of 5.3 is acidic and falls within the normal range for vaginal secretions, which are typically between 3.8 and 4.5. Amniotic fluid is alkaline, with a pH of 7.0 to 7.5. Therefore, an acidic pH does not indicate premature rupture of membranes.

Choice B rationale

Nitrazine paper turning dark blue indicates an alkaline pH, which is characteristic of amniotic fluid (pH 7.0-7.5). The presence of alkaline fluid in the vagina suggests premature rupture of membranes, as normal vaginal secretions are acidic.

Choice C rationale

A positive ferning test, where amniotic fluid dries in a fern-like pattern on a microscope slide, indicates the presence of amniotic fluid. A negative ferning test would suggest that the fluid is not amniotic fluid.

Choice D rationale

Nitrazine paper turning yellow indicates an acidic pH, which is consistent with normal vaginal secretions or urine. This finding would suggest that the fluid is not amniotic fluid, as amniotic fluid is alkaline and would turn the paper blue or dark blue.