Metabolic and Other Neonatal Emergencies: Hypoglycemia, Seizures, Jaundice, Sepsis and Fever, Vomiting, Diarrhea, Dehydration, and Neonatal Abstinence Practice Questions

25 multiple-choice questions on Metabolic and other neonatal emergencies: hypoglycemia, seizures, jaundice, sepsis and fever, vomiting, diarrhea, dehydration, and neonatal abstinence for paramedic and EMT students, from Chapter 43 (Neonatal Care). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. In the textbook, a newborn is considered hypoglycemic when the blood glucose falls below about:

   1. A. 70 mg/dL
   2. B. 100 mg/dL
   3. C. 40 mg/dL
   4. D. 20 mg/dL
   Show answer

   Answer: C. 40 mg/dL

   The textbook and many EMS protocols treat a newborn glucose below about 40 mg/dL as hypoglycemia, especially with symptoms. Hospital thresholds vary: the AAP (2011) gives IV dextrose to symptomatic infants below 40 mg/dL and uses lower cutoffs in the first hours for infants without symptoms, while the Pediatric Endocrine Society (2015) aims for above 50 mg/dL in the first 48 hours and above 60 mg/dL after that, so follow local protocol. Seventy mg/dL is a typical threshold for older children and adults, not a newborn treatment trigger in the first day. One hundred mg/dL is a normal glucose. Twenty mg/dL is severe hypoglycemia, and waiting for it would delay treatment. (AAP 2011; PES 2015; Caroline.)

2. The preferred site for obtaining a capillary blood glucose sample in a newborn is the:

   1. A. Tip of the index finger
   2. B. Lateral or medial heel
   3. C. Center of the heel pad
   4. D. Earlobe
   Show answer

   Answer: B. Lateral or medial heel

   The sides of the plantar heel are used because the center of the heel overlies the calcaneus, and a deep puncture there can cause osteomyelitis. A newborn's fingertips are too small for safe sampling.

3. Signs of hypoglycemia in a newborn are often subtle and may include:

   1. A. Polyuria, thirst, and weight loss
   2. B. Fever, bulging fontanelle, and rash
   3. C. Jitteriness, poor feeding, and apnea
   4. D. Rapid breathing, crackles, and edema
   Show answer

   Answer: C. Jitteriness, poor feeding, and apnea

   Newborns show hypoglycemia nonspecifically with jitteriness, lethargy, poor feeding, weak or high-pitched cry, apnea, hypothermia, and seizures. Polyuria, thirst, and weight loss suggest hyperglycemia; fever with a bulging fontanelle and rash points toward meningitis; and crackles with edema suggest heart failure.

4. The recommended IV dose of dextrose for a hypoglycemic newborn is:

   1. A. D10W 2 mL/kg (0.2 g/kg)
   2. B. D50W 1 mL/kg (0.5 g/kg)
   3. C. D25W 4 mL/kg (1 g/kg)
   4. D. D5W 20 mL/kg (1 g/kg)
   Show answer

   Answer: A. D10W 2 mL/kg (0.2 g/kg)

   Newborns receive 10% dextrose at 2 mL/kg, which gives 200 mg/kg without the vein damage and rebound caused by more concentrated solutions. D50 is far too hypertonic for neonatal veins.

5. A 4-kg newborn has a glucose of 28 mg/dL. Using D10W at 2 mL/kg, you should give:

   1. A. 4 mL
   2. B. 20 mL
   3. C. 40 mL
   4. D. 8 mL
   Show answer

   Answer: D. 8 mL

   Two milliliters per kilogram times 4 kg equals 8 mL of D10W. Forty milliliters is the 10 mL/kg volume used for fluid boluses, not for dextrose.

6. Which newborn is at highest risk for hypoglycemia in the first hours of life?

   1. A. A term infant breastfed at 1 hour
   2. B. The infant of a mother with diabetes
   3. C. A term infant of normal birth weight
   4. D. An infant born by planned cesarean
   Show answer

   Answer: B. The infant of a mother with diabetes

   Fetal exposure to high maternal glucose drives fetal insulin production, which continues after the glucose supply stops at birth. Prematurity, small or large size for age, sepsis, hypothermia, and asphyxia are other risk factors.

7. Seizures in a newborn may look different from those in older children. A typical neonatal seizure is:

   1. A. A long tonic-clonic seizure with incontinence
   2. B. Lip smacking, eye deviation, and bicycling
   3. C. A staring spell followed by an aura
   4. D. Repeated head drops with a loud cry
   Show answer

   Answer: B. Lip smacking, eye deviation, and bicycling

   Neonatal seizures are often subtle: eye deviation, blinking, sucking or lip smacking, bicycling movements, or apnea. Generalized tonic-clonic seizures are uncommon because the newborn brain is immature.

8. A 5-day-old infant is having repeated episodes of eye deviation and rhythmic leg movements. After the airway is managed, the first test you should perform is:

   1. A. A rectal temperature check
   2. B. A serum sodium level
   3. C. A serum calcium level
   4. D. A blood glucose level
   Show answer

   Answer: D. A blood glucose level

   Hypoglycemia is a common, quickly reversible cause of neonatal seizures, so glucose is checked first. Temperature matters for sepsis, and low sodium or calcium can also cause seizures, but those are laboratory tests, while a fingerstick glucose leads directly to a treatment you can give right away.

9. The most common cause of seizures in the first days of life is:

   1. A. Hypoxic-ischemic encephalopathy
   2. B. Febrile seizures from a viral illness
   3. C. Epilepsy inherited from a parent
   4. D. Head injury from a fall at home
   Show answer

   Answer: A. Hypoxic-ischemic encephalopathy

   Brain injury from birth asphyxia is the leading cause of neonatal seizures, followed by hemorrhage, infection, and metabolic causes such as low glucose or calcium. Febrile seizures occur in children from about 6 months to 5 years, not in newborns.

10. A newborn continues to seize after hypoglycemia is excluded. Under a typical EMS protocol, a first-line field medication is:

    1. A. Phenytoin given as a rapid IV push dose
    2. B. Diphenhydramine by IM injection
    3. C. A benzodiazepine such as midazolam
    4. D. Magnesium sulfate by IV infusion
    Show answer

    Answer: C. A benzodiazepine such as midazolam

    Most EMS protocols use a benzodiazepine, usually midazolam IM, IN, IV, or IO (or lorazepam), for a neonatal seizure that continues after glucose is checked and the airway is supported, with medical direction. In the hospital, phenobarbital is the first-line drug for neonatal seizures, so expect it after arrival. Phenytoin or fosphenytoin is a second-line hospital drug and cannot be pushed rapidly because of hypotension and dysrhythmias. Diphenhydramine has no antiseizure effect. Magnesium sulfate treats eclampsia in the mother, not seizures in the newborn. Be ready to ventilate, because benzodiazepines can cause apnea in newborns. (ILAE 2023; NASEMSO model guidelines.)

11. Jaundice that appears within the first 24 hours of life is:

    1. A. Physiologic and needs no follow-up
    2. B. Caused by breast milk in most cases
    3. C. Pathologic until proven otherwise
    4. D. Normal in infants born by cesarean
    Show answer

    Answer: C. Pathologic until proven otherwise

    Jaundice in the first day suggests hemolysis, as with blood-group incompatibility, or infection, and needs prompt evaluation. Physiologic jaundice typically appears after 24 hours and peaks around days 3 to 5.

12. The main danger of severe, untreated hyperbilirubinemia in a newborn is:

    1. A. Kernicterus, a bilirubin brain injury
    2. B. Liver failure from bile duct closure
    3. C. Kidney failure from pigment casts
    4. D. Heart failure from high cardiac output
    Show answer

    Answer: A. Kernicterus, a bilirubin brain injury

    Unconjugated bilirubin can cross the immature blood-brain barrier and damage the basal ganglia, causing lethargy, high-pitched cry, arching, and permanent disability. Phototherapy and exchange transfusion in the hospital prevent it.

13. A 2-week-old infant has a rectal temperature of 38.3 °C (100.9 °F) but looks well and is feeding. The appropriate management is:

    1. A. Give acetaminophen and observe at home
    2. B. Transport for a full sepsis evaluation
    3. C. Advise a recheck with the doctor tomorrow
    4. D. Treat as a cold and suggest fluids
    Show answer

    Answer: B. Transport for a full sepsis evaluation

    A rectal temperature of 38.0 °C (100.4 °F) or higher in an infant under about 28 days is treated as possible serious bacterial infection, regardless of appearance. Newborns can look well early in sepsis, so observing at home is unsafe.

14. In newborns, which temperature finding is a common sign of sepsis, especially in preterm infants?

    1. A. A high fever above 40 °C in most cases
    2. B. A normal temperature that rules sepsis out
    3. C. A low-grade fever after an immunization
    4. D. Hypothermia or an unstable temperature
    Show answer

    Answer: D. Hypothermia or an unstable temperature

    Newborns, especially preterm infants, often respond to infection with hypothermia or wide temperature swings rather than a high fever. A normal temperature does not exclude sepsis in a sick-appearing infant, and a low-grade fever after an immunization is usually a vaccine reaction rather than a sign of sepsis.

15. Risk factors for neonatal sepsis include:

    1. A. Planned cesarean delivery with the membranes still intact
    2. B. A first pregnancy with a quick, normal labor
    3. C. Maternal fever and rupture of membranes over 18 hours
    4. D. Delivery at term with clear amniotic fluid
    Show answer

    Answer: C. Maternal fever and rupture of membranes over 18 hours

    Prolonged rupture of membranes, maternal fever or chorioamnionitis, group B streptococcus colonization, and prematurity raise the risk of early-onset sepsis. A cesarean with intact membranes lowers exposure to vaginal organisms.

16. A newborn delivered at home has loops of intestine outside the abdomen through a defect beside the umbilical cord, with no covering sac. The best care is to:

    1. A. Push the bowel gently back inside the abdomen first
    2. B. Cover the bowel with dry gauze and tape it in place
    3. C. Place him face down so the bowel rests on the cot
    4. D. Wrap the bowel in a sterile plastic bag; keep warm
    Show answer

    Answer: D. Wrap the bowel in a sterile plastic bag; keep warm

    This is gastroschisis. Exposed bowel loses heat and fluid rapidly and can twist or lose its blood supply. Place the lower body and bowel in a sterile clear plastic bag or wrap, support the bowel so it does not kink, position the infant on his side, keep him warm, and transport to a center with pediatric surgery. Never try to replace it, and avoid dry gauze, which sticks.

17. A 3-day-old has not passed any stool since birth and now has a swollen belly and is vomiting. You should suspect:

    1. A. Normal newborn constipation that clears on its own
    2. B. A lower bowel blockage such as Hirschsprung disease
    3. C. Pyloric stenosis, which typically appears this early
    4. D. Gastroenteritis picked up in the hospital nursery
    Show answer

    Answer: B. A lower bowel blockage such as Hirschsprung disease

    Most term newborns pass meconium within 24 to 48 hours. No stool, a distended abdomen, and vomiting suggest a lower obstruction, such as Hirschsprung disease (missing nerve cells in the bowel) or meconium ileus. Pyloric stenosis appears at about 3 to 6 weeks and does not stop stools from the start.

18. A 10-day-old with diarrhea has a sunken anterior fontanelle, dry mucous membranes, and few wet diapers. These findings indicate:

    1. A. Significant dehydration
    2. B. Normal newborn findings
    3. C. Increased intracranial pressure
    4. D. Early bacterial meningitis
    Show answer

    Answer: A. Significant dehydration

    A sunken fontanelle, dry mouth, fewer wet diapers, and poor skin turgor indicate dehydration, which develops quickly in newborns because of their high water turnover. These are not normal findings; a well-hydrated newborn has a flat, soft fontanelle and moist mucous membranes. A bulging fontanelle, not a sunken one, suggests raised intracranial pressure. Meningitis in an infant tends to make the fontanelle full or bulging and causes fever or temperature instability, poor feeding, and lethargy rather than these signs of fluid loss. (Caroline, neonatal dehydration.)

19. Newborns become dehydrated faster than adults mainly because they have:

    1. A. A smaller share of body weight as water and slow turnover
    2. B. A larger share of body weight as water and high turnover
    3. C. Kidneys that concentrate urine better than an adult's
    4. D. Thicker skin that blocks most insensible water loss
    Show answer

    Answer: B. A larger share of body weight as water and high turnover

    Total body water is about 75% to 80% of a newborn's weight, and daily turnover is high, so losses from vomiting or diarrhea quickly deplete volume. A smaller water share with slow turnover describes older children and adults. Newborn kidneys concentrate urine poorly, which worsens fluid loss rather than protecting against it. Newborn skin is thin and lets more insensible water escape than an adult's, not less, especially in preterm infants. (Caroline, neonatal physiology.)

20. Signs of neonatal abstinence syndrome include:

    1. A. Lethargy, slow breathing, and constricted pupils
    2. B. Flushing, hypertension, and hives
    3. C. Tremors, high-pitched cry, and poor feeding
    4. D. Bradycardia, hypothermia, and floppy tone
    Show answer

    Answer: C. Tremors, high-pitched cry, and poor feeding

    Opioid withdrawal in the newborn causes irritability, tremors, a high-pitched cry, sneezing, yawning, sweating, diarrhea, and poor feeding. Lethargy, slow breathing, and small pupils are signs of opioid effect, not withdrawal.

21. A 24-hour-old infant of a mother who uses heroin daily is jittery and has a high-pitched cry. Naloxone is contraindicated because it can:

    1. A. Cause an opioid overdose in the infant
    2. B. Raise the blood glucose to unsafe levels
    3. C. Close the ductus arteriosus too early
    4. D. Cause acute withdrawal with seizures
    Show answer

    Answer: D. Cause acute withdrawal with seizures

    In an infant passively exposed to opioids in utero, naloxone can precipitate abrupt withdrawal and seizures. Supportive care, swaddling, a quiet environment, and hospital-directed treatment are used instead.

22. Withdrawal symptoms in a newborn exposed to methadone in utero may not appear until:

    1. A. Several days to 2 weeks after birth
    2. B. The first 2 hours after the birth
    3. C. The first feeding after the birth
    4. D. Six months after the infant's birth
    Show answer

    Answer: A. Several days to 2 weeks after birth

    Methadone and buprenorphine have long half-lives, so withdrawal may begin later and last longer than with heroin, which typically causes signs within 24 to 48 hours. Expecting signs within hours would miss most cases.

23. A 3-day-old infant is lethargic, feeding poorly, and has a temperature of 35.8 °C (96.4 °F), a heart rate of 190, and mottled skin. The most likely diagnosis is:

    1. A. Neonatal abstinence
    2. B. Hypothyroidism
    3. C. Reflux
    4. D. Sepsis
    Show answer

    Answer: D. Sepsis

    Lethargy, poor feeding, temperature instability, tachycardia, and poor perfusion in a newborn are sepsis until proven otherwise, and rapid transport with support of glucose, temperature, and breathing is needed. Neonatal abstinence causes irritability and tremors rather than lethargy and mottling, congenital hypothyroidism causes a slow rather than fast heart rate, and reflux causes spitting up in an infant who otherwise looks well, not shock.

24. Exposure of a newborn to cocaine or methamphetamine in utero is most associated with:

    1. A. Postterm birth and large size
    2. B. Prematurity and low birth weight
    3. C. Lower risk of placental abruption
    4. D. A long-delayed withdrawal syndrome
    Show answer

    Answer: B. Prematurity and low birth weight

    Stimulant use in pregnancy is linked to placental abruption, preterm birth, and growth restriction, and the infant may be irritable. These drugs do not usually cause a classic opioid-type withdrawal syndrome.

25. A newborn of a mother on magnesium sulfate for preeclampsia is floppy with weak respirations. The priority is to:

    1. A. Give calcium before ventilation
    2. B. Give naloxone by the IM route
    3. C. Support ventilation and monitor
    4. D. Place the infant prone and wait
    Show answer

    Answer: C. Support ventilation and monitor

    Maternal magnesium can cause newborn hypotonia and respiratory depression, which is managed with ventilatory support. Calcium may be considered in the hospital, but ventilation always comes first.