Hyperglycemia is a common finding in the extremely premature neonate, especially during the first several days of life. Premature neonates have difficulty maintaining normal blood glucose levels in spite of normal or below-normal glucose infusion rates. Some infants experience intermittent episodes of hyperglycemia throughout the course of hospitalization that typically can be related to infection, medications, overinfusion of glucose, or episodes of stress. Transient neonatal diabetes mellitus (TNDM) is an uncommon diagnosis that is utilized when other reasons for the hyperglycemia cannot be determined. The article presents a case study describing an episode of hyperglycemia that could have been TNDM or an exaggerated response to the use of dexamethasone.