A postpartum nurse is caring for a client and their newborn. Which of the following observations should indicate to the nurse that the client is in the taking-in phase of maternal role attainment?

A. Perform fetal scalp stimulation:

Fetal scalp stimulation involves applying pressure to the fetal scalp during a vaginal examination to elicit a response from the fetus, such as an acceleration of the fetal heart rate. While this can provide additional information about fetal well-being, it is not the initial priority when late decelerations are observed on the fetal monitor. The focus should first be on interventions aimed at improving fetal oxygenation to address the underlying cause of the late decelerations.

B. Administer oxygen via a face mask:

Administering oxygen to the mother is a priority intervention when late decelerations of the fetal heart rate are observed on the external fetal monitor. Late decelerations often indicate uteroplacental insufficiency, where the fetus is not receiving adequate oxygenation. Administering oxygen to the mother helps increase oxygen levels in her blood, improving oxygen delivery to the fetus and potentially mitigating the effects of uteroplacental insufficiency.

C. Elevate the client's head:

Elevating the client's head is not indicated when late decelerations are observed. This position could potentially compromise maternal-fetal circulation by reducing blood flow to the placenta. Maintaining a side-lying or semi-Fowler's position is often recommended to improve blood flow to the placenta and enhance fetal oxygenation.

D. Decrease the rate of IV fluids:

Adjusting the rate of IV fluids may be considered in some situations, such as if there is evidence of fluid overload or if the mother is receiving excessive amounts of IV fluids. However, it is not typically the initial intervention for addressing late decelerations. The focus should first be on interventions aimed at improving maternal-fetal oxygenation, such as administering oxygen and positioning the client appropriately.

A. Abdominal distention:

Abdominal distention is not typically associated with hypoglycemia in newborns. It may be caused by other factors such as swallowed air during feeding or gastrointestinal issues.

B. Acrocyanosis:

Acrocyanosis, which is the blueness of the hands and feet, is a common finding in newborns and is not specific to hypoglycemia. It is often a result of the newborn's immature circulatory system.

C. Temperature instability:

Temperature instability, including hypothermia or hyperthermia, can occur in newborns for various reasons, but it is not specific to hypoglycemia.

D. Hypotonia:

Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns. It may present as decreased activity, floppy movements, or poor feeding.

E.Jitteriness

Jitteriness, which is characterized by tremors or shaky movements, is a common manifestation of hypoglycemia in newborns. It is often observed when the newborn's blood glucose levels are low and can be a significant sign of hypoglycemia.