A nurse is caring for a preterm infant who is at risk for hypoglycemia. Which assessment finding would be the …

Question

A nurse is caring for a preterm infant who is at risk for hypoglycemia. Which assessment finding would be the MOST concerning and require immediate intervention?

Accepted Answer

보기 3: Lethargy with poor muscle tone and weak cry

Lethargy with poor tone and weak cry indicates CNS depression from severe hypoglycemia, requiring immediate glucose to prevent brain damage. Other options represent earlier or less severe signs that may allow for monitoring or less urgent care.

Answer

보기 1: Jitteriness and irritability during handling

Answer

보기 2: Blood glucose level of 40 mg/dL (2.2 mmol/L) with no symptoms

Answer

보기 4: Temperature instability with cool extremities

Concept	Description	Nursing Implication
Neonatal Hypoglycemia	Blood glucose < 40 mg/dL (2.2 mmol/L) in term infants; often lower threshold for preterms. Caused by depleted stores, hyperinsulinism, or increased use.	Monitor glucose per protocol (often at 1, 2, 4, 8, 12, 24 hrs of life). Early feeding is preventive.
Adrenergic (Early) Signs	Jitteriness, irritability, tachycardia, sweating, hunger. Caused by catecholamine release.	Prompt intervention needed (feed or give glucose), but indicates compensatory mechanisms are working.
Neuroglycopenic (Late) Signs	Lethargy, hypotonia (poor muscle tone), weak cry, apnea, seizures, coma. Caused by brain energy failure.	MEDICAL EMERGENCY. Requires immediate IV dextrose (e.g., D10W bolus) and continuous support.
Preterm Infant Risks	Limited glycogen/fat stores, immature liver enzymes (gluconeogenesis), poor feeding, high metabolic rate.	Proactive surveillance is key. Hypoglycemia is a common complication of prematurity.

Assessment Finding	What It Indicates	Urgency Level	Typical Intervention
Lethargy, Hypotonia, Weak Cry	Severe hypoglycemia with CNS depression. Brain injury imminent.	HIGHEST - Immediate	STAT IV dextrose bolus, airway support, continuous glucose infusion.
Jitteriness, Irritability	Early/moderate hypoglycemia. Body is still compensating.	High - Prompt	Attempt feeding (breast/bottle). If persists or feeding not possible, give oral glucose gel or IV dextrose.
Asymptomatic Low Glucose	Lab value abnormality without clinical signs. Infant may be compensating.	Moderate - Protocol-based	Feed or give IV dextrose per unit protocol to prevent progression to symptomatic state.
Temperature Instability	Cold stress, which can lead to or worsen hypoglycemia.	Moderate - Requires action	Place in warmed isolette, use radiant warmer. Monitor glucose closely.

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A nurse is caring for a preterm infant who is at risk for hypoglycemia. Which assessment finding would be the MOST concerning and require immediate intervention?

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