Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 8 to 10 minutes, lasting about 30 seconds. The nurse determines that this client is in:
Select one:

Choice A Reason: Prepare for IV dextrose administration. This is an incorrect answer that indicates an unnecessary and invasive intervention for an IDM with normal blood glucose. IV dextrose administration is indicated for an IDM with severe or persistent hypoglycemia, which is defined as a blood glucose below 40 mg/dL or below 60 mg/dL after two feedings.

Choice B Reason: Provide routine care, per hospital IDM protocol. This is because a blood glucose of 60 is within the normal range for an IDM, which is 40 to 80 mg/dL. An IDM is a newborn whose mother has pre-existing or gestational diabetes, which can affect the fetal and neonatal glucose metabolism and regulation. An IDM may have hypoglycemia (low blood glucose), hyperglycemia (high blood glucose), or other complications such as macrosomia, polycythemia, or congenital anomalies. An IDM requires routine care and monitoring according to the hospital IDM protocol, which may include blood glucose testing, feeding, temperature regulation, and observation for signs of distress.

Choice C Reason: Place the infant in a warmed incubator. This is an incorrect answer that suggests an irrelevant and potentially harmful action for an IDM with normal blood glucose. Placing the infant in a warmed incubator is indicated for an IDM with hypothermia, which is a low body temperature that can impair glucose utilization and increase oxygen consumption. However, placing the infant in a warmed incubator without proper indication can cause hyperthermia, which is a high body temperature that can lead to dehydration, electrolyte imbalance, or brain damage.

Choice D Reason: Alert the clinician immediately for orders. This is an incorrect answer that implies an urgent and unwarranted situation for an IDM with normal blood glucose. Alerting the clinician immediately for orders is indicated for an IDM with signs of distress or complications, such as apnea, cyanosis, seizures, or jaundice.

Choice A Reason: A fetal heart rate baseline of 140 with one acceleration to 155 for 15 seconds within 30 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. A non-reactive NST may suggest fetal hypoxia, distress, or sleep, but it does not necessarily indicate a problem. A non-reactive NST may require further testing or stimulation to elicit a reactive result.

Choice B Reason A fetal heart rate baseline of 140 with two accelerations to 160 for 15 seconds within 20 minutes. This is because this strip meets the criteria for a reactive NST, which is a non-invasive test that evaluates fetal well- being and oxygenation by measuring the fetal heart rate response to fetal movements. A reactive NST is defined as having at least two accelerations of the fetal heart rate that are at least 15 beats per minute above the baseline and last for at least 15 seconds within a 20-minute period.

Choice C Reason: A fetal heart rate baseline of 130 with two accelerations to 135 for 15 seconds within 20 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. The accelerations in this strip are not sufficient in amplitude, as they are only 5 beats per minute above the baseline, instead of at least 15 beats per minute.

Choice D Reason: A fetal heart rate baseline of 150 with two accelerations to 160 for 10 seconds within 20 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. The accelerations in this strip are not sufficient in duration, as they last only for 10 seconds, instead of at least 15 seconds.