Exhibits

Question 2(B) Complete the following sentence by using the lists of options. The nurse should first

dropdown

before performing a heel stick, followed by

dropdown

.

Heel warming increases capillary blood flow, improving sample accuracy and reducing hemolysis risk. Capillary glucose testing requires adequate perfusion for reliable results. Breastfeeding provides immediate glucose substrate to correct mild hypoglycemia. Normal neonatal blood glucose is >40–45 mg/dL; this newborn’s initial level of 35 mg/dL is below threshold, but responsive to feeding. Breast milk contains lactose, metabolized to glucose and galactose, supporting cerebral energy demands.

Rationale for incorrect Response 1 options: Administer glucose gel is appropriate only if feeding fails or glucose remains <25 mg/dL in asymptomatic or <40 mg/dL in symptomatic neonates. This newborn improved with feeding. Start IV fluids is reserved for persistent hypoglycemia or symptomatic neonates unresponsive to oral intake. The newborn stabilized post-breastfeeding. Phototherapy treats hyperbilirubinemia, not hypoglycemia. No bilirubin levels or jaundice signs were reported.

Rationale for incorrect Response 2 options: Supplement with formula is secondary to breastfeeding unless maternal milk is unavailable or ineffective. Breastfeeding was successful post-latch correction. Administer insulin is contraindicated; insulin lowers glucose and is used only in hyperglycemia. Monitor for jaundice is unrelated to hypoglycemia management unless bilirubin levels are elevated. No clinical jaundice was noted.

Take-home points:

• Neonatal hypoglycemia is defined as glucose <40–45 mg/dL; early feeding is first-line intervention.
• Macrosomic infants (birth weight >4,000 g) are at risk due to hyperinsulinemia post-placental glucose withdrawal.
• Differentiate hypoglycemia from sepsis, hypothermia, and metabolic disorders—all may present with jitteriness and hypotonia.
• Capillary sampling requires heel warming to ensure perfusion and accurate glucose measurement.

Choice A rationale

Elevated maternal serum alpha-fetoprotein (MSAFP) levels are more often associated with intrauterine growth restriction (IUGR) due to placental compromise, which can lead to increased leakage of AFP into the maternal circulation. AFP is a glycoprotein produced by the fetal liver and yolk sac. Normal MSAFP levels vary by gestational week, but generally, a level ≥ 2.5 Multiples of the Median (MoM) is considered elevated.

Choice B rationale

Multiple gestation, such as twins or triplets, typically results in an elevated MSAFP because there are multiple fetuses producing AFP, leading to a higher total concentration in the maternal serum. This physiological increase requires adjustment of the median value used for interpretation to prevent false-positive results for neural tube defects.

Choice C rationale

Down syndrome (Trisomy 21) is associated with low MSAFP levels, often ≤ 0.75 MoM, along with decreased unconjugated estriol and increased human chorionic gonadotropin (hCG) and inhibin A in the quad screen. This specific pattern is due to complex, poorly understood pathophysiology related to the aneuploidy's effect on fetal protein synthesis and maternal-fetal exchange.

Choice D rationale

Neural tube defects (NTDs), such as spina bifida and anencephaly, are associated with markedly elevated MSAFP levels, usually ≥ 2.5 MoM. This is caused by the exposed fetal meninges or neural tissue leaking a large amount of AFP directly into the amniotic fluid, which then diffuses into the maternal circulation.