“A nurse is caring for a patient who reports spontaneous rupture of membranes.

The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding.

After calling for assistance and notifying the provider, which of the following actions should the nurse take next?”

Choice A rationale
Jitteriness is a common sign of hypoglycemia in newborns. Newborns whose mothers had gestational diabetes are at an increased risk of developing hypoglycemia shortly after birth. Other signs of neonatal hypoglycemia can include poor feeding, lethargy, and seizures.
Choice B rationale
Increased muscle tone is not typically associated with hypoglycemia in newborns. However, decreased muscle tone can be a sign of severe hypoglycemia.
Choice C rationale
Abdominal distention is not typically associated with hypoglycemia in newborns. However, it can be a sign of other conditions, such as gastrointestinal obstruction or sepsis.
Choice D rationale
Petechiae, or small red or purple spots on the skin caused by bleeding into the skin, are not typically associated with hypoglycemia in newborns. However, they can be a sign of other conditions, such as infection or a bleeding disorder.

Choice A rationale
Epigastric discomfort is not typically associated with pyelonephritis. It may be a symptom of other conditions such as gastrointestinal issues or preeclampsia.
Choice B rationale
Abdominal cramping is not a typical manifestation of pyelonephritis. It could be a symptom of various other conditions, including gastrointestinal disorders or gynecological issues.
Choice C rationale
A temperature of 37.2°C (99.8°F) is within the normal range and is not indicative of pyelonephritis. Pyelonephritis, an infection of the kidneys, is typically associated with a high fever.
Choice D rationale
Flank pain is a common manifestation of pyelonephritis. This is because the kidneys, which are affected in pyelonephritis, are located in the flank area.