The nursery has just admitted a new infant born 1 hour ago. While performing an assessment, the nurse suspects the infant may have hypoglycemia based on which of the following assessment data? Select all that apply
A) Heel stick glucose value of 50 mg/dL
B) Infant having periods of apnea requiring physical stimulation
C) Muscle twitching noted while lying in crib undisturbed by nurses
D) Hyperactive reflexes noted especially when crying
E) Poor suck reflex resulting in an inability to feed properly
Ans:
B, C, E
Feedback:
In neonates, glucose levels stabilize to a value of 50 mg/dL or higher within the first 3 hours of life. Concentrations below 45 mg/dL should be considered abnormal. Signs and symptoms of neonatal hypoglycemia include cyanosis, apnea, hypothermia, hypotonia, poor feeding, lethargy, and seizures.
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