The nurse collects client data and determines the newborn is most likely experiencing hypoglycemia as evidenced by which of the following?

Jitteriness.

Increased temperature.

Brisk reflexes.

Absence of a Moro reflex.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Hypoglycemia in a newborn, defined as a plasma glucose level typically below 40 to 50 mg/dL, starves the central nervous system of its primary energy source, glucose. This lack of fuel in the brain cells often presents with neurological symptoms. Jitteriness (or tremors) is a classic and early neurogenic sign of this metabolic disturbance, resulting from sympathetic nervous system activation.

Choice B rationale

Hypoglycemia typically results in an attempt by the body to conserve energy and may lead to poor peripheral perfusion and decreased metabolic rate, which often manifests as hypothermia (decreased temperature). Increased temperature (hyperthermia) is not a sign of hypoglycemia; instead, it is often associated with infection or environmental overheating.

Choice C rationale

Hypoglycemia causes central nervous system instability and depression, which generally results in a decrease in a newborn's reflexes and muscle tone (hypotonia), or can lead to lethargy and poor feeding. Therefore, brisk reflexes (hyperreflexia) are not a characteristic finding and would suggest other neurological or metabolic conditions.

Choice D rationale

The Moro reflex (or startle reflex) is a complex, primitive reflex that is present and intact in healthy newborns. While severe hypoglycemia can lead to generalized central nervous system depression, which could eventually suppress all reflexes, an absence of a Moro reflex is a more specific sign of a severe neurological injury or a congenital neurological disorder, not a typical early sign of hypoglycemia.

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Correct Answer is C

Explanation

Choice A rationale

Weighing a newborn's wet diaper is an essential component of monitoring fluid balance and renal function, which is critical as neonatal abstinence syndrome (NAS) infants may have diarrhea leading to fluid loss. However, it is not the first priority action. NAS symptoms, caused by central nervous system hyperexcitability, necessitate stabilization of vital functions, with respiratory status being paramount. Normal urine output for a newborn is typically 1-3 mL/kg/hr.

Choice B rationale

Swaddling provides non-pharmacological comfort by simulating the confined uterine environment, reducing excessive stimulation, and minimizing the hyperirritability and tremors associated with central nervous system dysfunction in neonatal abstinence syndrome. While a beneficial and frequent intervention, stabilizing the newborn's physiological status, specifically respiratory effort and rate, must be assessed and secured as the immediate priority due to potential for respiratory distress.

Choice C rationale

Determining the newborn's respiratory rate is the highest priority because respiratory depression and distress are critical potential complications in a newborn experiencing neonatal abstinence syndrome, often associated with poly-drug exposure or direct effects of opioids. NAS can lead to hyperthermia and increased metabolic demand, escalating oxygen consumption. A normal newborn respiratory rate is typically 30 to 60 breaths per minute; deviations require immediate intervention.

Choice D rationale

Auscultating the newborn's bowel sounds assesses gastrointestinal motility, which can be affected by the hyper-excitability seen in NAS, potentially leading to diarrhea, poor feeding, and fluid-electrolyte imbalances. However, this assessment is secondary to ensuring adequate oxygenation and ventilation, which is always the initial and most crucial step in the hierarchy of needs for any compromised neonate experiencing withdrawal symptoms.

A. Allow private bonding time for the parents and newborn. B. Apply the identification bands to the newborn and the mother. C. Dry the newborn with clean towels. D. Check the newborn's axillary temperature.

Correct Answer is C

Explanation

Choice A rationale

While bonding time is crucial for establishing parent-newborn attachment, it is not the immediate priority during the third stage of labor. The third stage is the period from the baby's birth until the placenta is delivered. The newborn's physiological stability, particularly temperature regulation and respiratory transition, takes precedence over private bonding immediately after birth.

Choice B rationale

Applying identification bands is a critical safety measure to prevent infant abduction or mix-up. However, it is not the absolute first action the nurse should take. Thermoregulation and initial stabilization, such as drying, are the immediate priorities to prevent cold stress and ensure the newborn's physiological adaptation before applying bands or allowing prolonged bonding.

Choice C rationale

Drying the newborn with clean towels is the first and most critical action to prevent heat loss through evaporation. Immediate drying and removing the wet linens are essential for thermoregulation and preventing cold stress, which can lead to increased oxygen consumption and metabolic acidosis. This action also provides tactile stimulation, which can help initiate or sustain respirations.

Choice D rationale

Checking the newborn's axillary temperature is an essential step for monitoring thermoregulation. However, it is an assessment action that follows the intervention of drying the baby. Immediate drying is the priority to prevent heat loss and stabilize the baby's temperature; the temperature check is then used to evaluate the effectiveness of the warming measures.

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The nurse collects client data and determines the newborn is most likely experiencing hypoglycemia as evidenced by which of the following?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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