Three hours after birth, a newborn becomes jittery and tachypneic

Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?

A.
Obtain a capillary glucose level.

B.
Feed 30 mL of 10% dextrose in water.

C.
Wrap tightly in a blanket.

D.
Encourage the mother to breastfeed.

The Correct Answer and Explanation is:

Correct Answer: A. Obtain a capillary glucose level.

Explanation:

In the scenario where a newborn becomes jittery and tachypneic three hours after birth, the first step the nurse should take is to obtain a capillary glucose level. These symptoms are commonly associated with hypoglycemia, which is a critical condition in newborns and requires prompt assessment and intervention.

Understanding Neonatal Hypoglycemia: Neonatal hypoglycemia occurs when a newborn’s blood glucose level falls below the normal range. This condition is particularly common in newborns, especially those who are preterm, small for gestational age, large for gestational age, or infants of diabetic mothers. Symptoms of neonatal hypoglycemia include jitteriness, tachypnea (rapid breathing), cyanosis, weak or high-pitched cry, poor feeding, lethargy, and in severe cases, seizures.

Why Glucose Level Measurement is Crucial: Jitteriness and tachypnea are non-specific symptoms, meaning they can be caused by various conditions. However, hypoglycemia is a common and dangerous cause that must be ruled out immediately. Measuring the capillary glucose level allows the nurse to quickly determine whether the newborn’s symptoms are due to hypoglycemia, enabling timely intervention to prevent further complications such as neurological damage.

Other Options:

• B. Feed 30 mL of 10% dextrose in water: While administering glucose is appropriate in treating hypoglycemia, it should only be done after confirming the condition with a glucose measurement. Immediate feeding without confirmation could mask symptoms of other underlying issues.
• C. Wrap tightly in a blanket: Wrapping a newborn can help in maintaining body temperature, but it does not address the underlying cause of jitteriness and tachypnea.
• D. Encourage the mother to breastfeed: Breastfeeding is beneficial and can prevent hypoglycemia, but it is not the first step in a situation where hypoglycemia is suspected. The nurse must first confirm the glucose level and then decide on the appropriate feeding intervention.

Conclusion: In summary, obtaining a capillary glucose level is the most appropriate initial action. It directly addresses the most likely and potentially life-threatening cause of the newborn’s symptoms. Once hypoglycemia is confirmed, appropriate treatment, such as feeding or administering glucose, can be initiated to stabilize the newborn’s condition.