A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus B-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?

Explanation

Choice A Reason:

Abdominal distention is not a typical manifestation of hypoglycemia in newborns. It may indicate other issues such as gastrointestinal discomfort, intestinal obstruction, or excessive gas accumulation.

Choice B Reason:

Jitteriness is correct. Hypoglycemia in newborns can occur, particularly if the mother had gestational diabetes mellitus (GDM). Jitteriness is one of the common manifestations of hypoglycemia in newborns. Other signs may include poor feeding, lethargy, sweating, cyanosis, respiratory distress, and seizures.

Choice C Reason:

Petechiae are small, pinpoint hemorrhages in the skin caused by bleeding under the skin. While petechiae can occur due to various reasons, including neonatal sepsis or birth trauma, they are not typically associated with hypoglycemia.

Choice D Reason:

Increased muscle tone is incorrect. Hypoglycemia in newborns usually presents with decreased muscle tone rather than increased muscle tone. Increased muscle tone is more commonly associated with conditions such as hypocalcemia or central nervous system disorders.

Choice A Reason:

Instruct the client to empty their bladder: Emptying the bladder before the examination allows for better visualization and palpation of the uterus and fetal parts. A full bladder can interfere with the ability to assess the position, presentation, and engagement of the fetus accurately.

Choice B Reason:

Position the client supine with knees flexed and place a small, rolled towel under one of their hips: Positioning the client supine with knees flexed helps relax the abdominal muscles and provides better access to the uterus for palpation. Placing a small, rolled towel under one hip helps tilt the pelvis slightly, which can improve visualization and palpation of the uterine fundus.

Choice C Reason:

Palpate the fetal part positioned above the symphysis pubis: Palpating the fetal part above the symphysis pubis (typically the fetal head) allows the healthcare provider to determine the presenting part, engagement, and degree of descent of the fetus. This step provides valuable information about the fetal position and presentation.

Choice E Reason:

Palpate the fetal parts along both sides of the uterus: Palpating the fetal parts along both sides of the uterus helps the healthcare provider identify the fetal back and limbs. This step provides further confirmation of the fetal position and presentation and helps assess fetal lie and attitude.

Choice D Reason:

Palpate the fetal part positioned in the fundus: Palpating the fetal part in the fundus (typically the buttocks or head) confirms the findings from the previous steps and helps determine the presenting part and its relationship to the maternal pelvis. This step provides additional information about the fetal position, presentation, and engagement, which is crucial for assessing fetal well-being and planning for labor and delivery.