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 {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Rationale for correct answers: Transient hypoglycemia is common in the first hours of life, especially in macrosomic infants due to maternal hyperglycemia-induced fetal hyperinsulinemia. Blood glucose <40–45 mg/dL is abnormal; this newborn had 35 mg/dL initially, improved to 50 mg/dL after feeding. Symptoms like jitteriness, abnormal cry, and mild hypotonia resolved post-breastfeeding. Breastfeeding provides lactose, which is hydrolyzed to glucose and galactose, correcting hypoglycemia physiologically. Early feeding is first-line for asymptomatic or mildly symptomatic neonates with glucose >25 mg/dL.

Rationale for incorrect Response 1 options: Signs of infection (e.g., temperature instability, poor feeding, lethargy) may overlap with hypoglycemia but require systemic signs and lab confirmation. This newborn improved with feeding and had no fever, tachypnea, or leukocytosis. Respiratory distress presents with grunting, nasal flaring, retractions, and desaturation. The newborn’s respiratory rate was normal (45/min), no distress signs noted. Hyperbilirubinemia manifests as jaundice, typically after 24 hours. No yellowing of skin or sclera was reported; phototherapy is not indicated.

Rationale for incorrect Response 2 options: Administer antibiotics is appropriate for suspected sepsis, not isolated hypoglycemia. No infectious signs or risk factors were present. Provide oxygen support is reserved for respiratory compromise. The newborn had stable vitals and no hypoxia. Initiate phototherapy treats elevated bilirubin. No bilirubin levels or jaundice signs were documented.

Take-home points:

Transient neonatal hypoglycemia is common in macrosomic infants due to hyperinsulinemia.
Early breastfeeding is the preferred intervention for mild hypoglycemia with stable vitals.
Differentiate hypoglycemia from sepsis and respiratory distress using targeted clinical signs.
Phototherapy is reserved for hyperbilirubinemia; not indicated without jaundice or elevated bilirubin.

A. Weigh the newborn's wet diaper. B. Swaddle the newborn in blankets. C. Determine the newborn's respiratory rate. D. Auscultate the newborn's bowel sounds.

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.

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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

Exhibits A nurse on the labor and delivery unit is continuing to assist in the care of a newborn. Complete the following sentence by using the lists of options. Because the newborn is exhibiting dropdownthe nurse should plan todropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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