# A nurse is assessing a 4200-gram newborn born at 38 weeks gestation to a mother with gestational diabetes who is large for gestational age (LGA). Which assessment finding would be the priority concern for this infant?

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> subject: Maternal Newborn Health

## 문제

A nurse is assessing a 4200-gram newborn born at 38 weeks gestation to a mother with gestational diabetes who is large for gestational age (LGA). Which assessment finding would be the priority concern for this infant?

The nurse is caring for a 4200-gram newborn born at 38 weeks gestation to a mother with gestational diabetes.

## 보기

1. Decreased muscle tone and weak cry
2. Excessive weight loss in the first 24 hours
3. Blood glucose level of 35 mg/dL at 2 hours of age **✔ 정답**
4. Difficulty with initial feeding attempts

**정답: 3**

## 해설

LGA infants are at high risk for hypoglycemia due to hyperinsulinemia from maternal glucose exposure in utero. A blood glucose level of 35 mg/dL at 2 hours of age requires immediate intervention to prevent neurological complications.

## 심화 해설

Clinical Context

This newborn presents with a classic triad of risk factors for neonatal metabolic complications: large for gestational age (LGA) status with a birth weight of 4200 grams, maternal gestational diabetes mellitus (GDM), and early transitional physiology. In infants of diabetic mothers (IDMs), the intrauterine environment of maternal hyperglycemia drives fetal hyperinsulinemia. After delivery, when the continuous placental glucose supply is abruptly severed, the neonate's elevated circulating insulin persists, rapidly driving down blood glucose levels. This pathophysiologic sequence makes neonatal hypoglycemia the most immediate and potentially neurotoxic threat during the transitional period [4].

Priority Assessment Analysis

The blood glucose value of 35 mg/dL at 2 hours of age falls below the commonly accepted clinical threshold for neonatal hypoglycemia. While exact definitions vary, a value of

## 임상 시나리오

Clinical Case: Priority Assessment in an Infant of a Diabetic Mother

**Scenario:** A 4200-gram, 38-week gestation newborn, classified as large for gestational age (LGA) and born to a mother with gestational diabetes, is in the transitional nursery. At 2 hours of age, the point-of-care blood glucose is 35 mg/dL.

Clinical Practice Guideline: Management of Neonatal Hypoglycemia

For an asymptomatic or symptomatic infant with a blood glucose < 40-45 mg/dL in the first 24 hours, immediate intervention is required to prevent neuroglycopenia and potential long-term neurological sequelae. The priority is to confirm the low reading and restore euglycemia.

- **Immediate Action:** If the infant is symptomatic (e.g., jittery, lethargic, poor tone) or the glucose is < 25 mg/dL, administer an IV bolus of 2 mL/kg of 10% dextrose in water (D10W) and initiate a continuous IV infusion of D10W at 80-100 mL/kg/day. For an asymptomatic infant with a glucose of 35 mg/dL, a feeding intervention (breastfeeding or formula) is the first step, with a recheck 30 minutes post-feed. If glucose remains < 40 mg/dL, escalate to IV therapy.

- **Monitoring:** Perform pre-feed blood glucose checks every 2-3 hours for the first 24 hours for at-risk infants (IDMs, LGA, preterm). Once stable, checks can be spaced to before every other feed.

- **Pathophysiology:** The infant's hyperinsulinemic state, driven by maternal hyperglycemia, suppresses lipolysis and ketogenesis, depleting alternative brain fuels and increasing the risk of neuronal injury during hypoglycemia.

- **Nursing Priority:** Frequent, protocol-driven glucose surveillance takes precedence over routine newborn care tasks. Early identification and treatment of hypoglycemia are critical for neuroprotection.

**Reference:** Committee on Fetus and Newborn, Adamkin DH. Postnatal glucose homeostasis in late-preterm and term infants. *Pediatrics*. 2011;127(3):575-579.

## 핵심 개념

- **Large for Gestational Age** — Newborn whose weight is at or above the 90th percentile for gestational age. Generally, birth weight is 4000 g (4 kg) or more.
- **Neonatal Hypoglycemia** — Neonatal hypoglycemia. A condition where blood glucose levels are below 40 mg/dL within 24 hours of birth. It is common in LGA infants and babies of diabetic mothers, and there is a risk of neurological damage.
- **Hyperinsulinemia** — Hyperinsulinemia. A condition where the blood insulin level is abnormally high. The fetus of a diabetic mother overproduces insulin in response to intrauterine hyperglycemia, which leads to hypoglycemia after birth.
- **Gestational Diabetes Mellitus** — Gestational diabetes. Diabetes first discovered or started during pregnancy. It is a major risk factor for fetal LGA and neonatal hypoglycemia.
- **Birth Injury (e.g., Clavicle Fracture)** — Birth injury (e.g., clavicle fracture). This is a complication that can occur in LGA newborns during vaginal delivery due to shoulder dystocia, among other causes. It is a problem to watch for after hypoglycemia.

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