A nurse is completing a full assessment of a newborn at 4 hours of life.

For each of the assessment findings below, click to specify if this is an expected (normal) newborn finding or an abnormal finding.

Note: each column must have at least one response option selected.

Choice A rationale

Hyperbilirubinemia, or high levels of bilirubin in the blood, can occur in newborns of diabetic mothers due to increased red blood cell breakdown. However, it is not the primary concern immediately after birth. The priority is to address conditions that can cause immediate harm, such as hypoglycemia.

Choice B rationale

Hypomagnesemia, or low magnesium levels, can occur in newborns of diabetic mothers, but it is not the most critical issue. Magnesium levels can be monitored and corrected if necessary, but hypoglycemia poses a more immediate threat to the newborn’s health.

Choice C rationale

Hypocalcemia, or low calcium levels, can also occur in newborns of diabetic mothers. While it is important to monitor and manage calcium levels, hypoglycemia is a more urgent concern because it can lead to severe complications if not addressed promptly.

Choice D rationale

Hypoglycemia, or low blood sugar levels, is the most critical concern for newborns of diabetic mothers. These newborns are at high risk for hypoglycemia due to the high levels of insulin they produce in response to their mother’s elevated blood glucose levels during pregnancy. Hypoglycemia can cause serious complications, including seizures and brain damage, if not treated immediately.

Choice A rationale

A newborn with a temperature of 37.0°C (98.6°F) is within the normal range for newborns and does not require immediate intervention.

Choice B rationale

A newborn who has not voided within 27 hours post-delivery requires immediate intervention. Newborns should void within the first 24 hours of life. Failure to void may indicate dehydration, urinary tract obstruction, or renal issues.

Choice C rationale

A newborn who has not passed meconium within 18 hours post-delivery is concerning but not as urgent as not voiding. Newborns typically pass meconium within the first 24-48 hours.

Choice D rationale

Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves on its own. It does not require immediate intervention.