A client in labour admits to using alcohol throughout the pregnancy. The most recent use the day before. Based on the client's history, the nurse should give priority to assessing the newborn for?

1. A

   Respiratory depression

2. B

   Wide-set eyes

3. C

   Jitteriness

4. D

   Low-set ears

Appeared in: DHS Staff Nurse - 2018 (Shift-2nd)

Explanation

• Jitteriness is a primary sign of central nervous system (CNS) hyperirritability resulting from acute alcohol withdrawal in the newborn.
• The mother's recent alcohol consumption places the infant at high risk for withdrawal symptoms, which typically begin within hours after birth as the maternal alcohol supply is cut off.
• Jitteriness is also a classic sign of hypoglycemia (low blood sugar), a common and serious metabolic complication in infants prenatally exposed to alcohol.
• Assessing for jitteriness is a priority because it can signal impending seizures or severe metabolic distress, both of which require immediate medical intervention to prevent brain injury.

Why Other Options Were Wrong

• Option A: Significant respiratory depression is not a characteristic sign of alcohol withdrawal in newborns. It is the hallmark sign of neonatal depression from maternal opioid use (e.g., heroin, methadone), barbiturates, or general anesthesia.
• Option B: Wide-set eyes (hypertelorism) are a structural anomaly, not an acute physiological symptom. While assessing for dysmorphic features is part of the complete newborn examination, it is not the immediate priority over assessing for life-threatening withdrawal or metabolic issues. Furthermore, wide-set eyes are not a classic feature of Fetal Alcohol Syndrome (FAS); the classic facial triad is short palpebral fissures, a smooth philtrum, and a thin upper lip.
• Option D: Low-set ears are a physical anomaly that can be associated with various congenital conditions, including FASD. However, like wide-set eyes, this is a structural finding, not a sign of acute distress. The priority at birth is to ensure physiological stability.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Priority nursing assessment for a newborn exposed to maternal alcohol use in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Early recognition of jitteriness as a sign of withdrawal or hypoglycemia is a critical nursing responsibility that allows for timely intervention, preventing severe outcomes like seizures and long-term neurological damage.
• Nurses must be prepared to implement the 'Eat, Sleep, Console' approach, which prioritizes non-pharmacologic care like swaddling, a low-stimulus environment, and consistent feeding to manage withdrawal symptoms.
• What if the mother's last drink was in the first trimester, with no use since? The priority at birth would shift from assessing for acute withdrawal to performing a detailed physical examination for the characteristic facial features and growth deficiencies of Fetal Alcohol Spectrum Disorders (FASD), as the risk of acute withdrawal would be negligible.

How to Approach the Question

• First, identify that this is a priority question. The keyword 'priority' directs you to select the most urgent and potentially life-threatening issue.
• Analyze the clinical scenario: The mother consumed alcohol the day before delivery. This is a critical piece of data, indicating a high risk for acute problems in the newborn.
• Evaluate each option based on urgency and pathophysiology. Differentiate between acute physiological signs (like jitteriness) and chronic structural findings (like facial features).
• Recall that alcohol withdrawal in a newborn manifests as CNS hyperirritability. Jitteriness is a classic sign of this.
• Also, remember that alcohol exposure puts the infant at risk for hypoglycemia, which also presents with jitteriness.
• Eliminate options that are less likely or less urgent. Respiratory depression is more common with opioids. Dysmorphic features are important but not an immediate life threat.

Concept Tested & Keywords

• Concept Tested: Priority nursing assessment for a newborn exposed to maternal alcohol use.
• Stem keywords: labour, alcohol throughout pregnancy, newborn, priority assessment
• Lead-in keywords: priority
• Clinical cues: The most recent alcohol use was the day before delivery, which significantly increases the risk of acute neonatal withdrawal symptoms shortly after birth.

Question ID

Qj8SeNrWXXCQAWlAT9KL42

Copy ID

Reference Book

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 1144-1146

E6 Kaplan Sadock's Synopsis of Psychiatry-2022 (pp 1-3768 of 3768) pp. 340-342, 2787-2789