The nurse should further evaluate the cry characteristics, muscle tone, and respiratory characteristics to determine if the newborn is experiencing a complication.

Choice A rationale

Folic acid, a B vitamin (B9), is essential for DNA synthesis and cell division, critical processes during early fetal development, but it is not primarily responsible for preventing fetal bleeding. The prevention of bleeding is primarily linked to adequate Vitamin K and factors necessary for the coagulation cascade and platelet function. Therefore, this statement indicates a misunderstanding of folic acid's specific role.

Choice B rationale

While folic acid supports general cell health, including rapid cell division in the immune system, its most direct and critical role in early pregnancy is the prevention of neural tube defects. Strengthening the immune system is a function often more directly associated with nutrients like Vitamin C, Vitamin D, or other micronutrients, indicating an incomplete understanding of its primary prenatal benefit.

Choice C rationale

Folic acid's primary action is in cellular proliferation and differentiation, specifically in neural tissue. Bone strength relies primarily on the adequate intake and absorption of calcium and Vitamin D, which regulate bone mineralization. Therefore, linking folic acid directly to bone strength demonstrates a fundamental misunderstanding of its primary physiological function during early gestation.

Choice D rationale

Folic acid is vital for the development and closure of the fetal neural tube during the first 28 days of gestation, significantly reducing the risk of neural tube defects (NTDs) like spina bifida and anencephaly. This statement accurately reflects the most critical and evidence-based reason for adequate periconceptional and early prenatal folic acid supplementation, indicating correct understanding.

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.