A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?

The correct answer is A. Jitteriness.

A. Jitteriness: Jitteriness is a common manifestation of hypoglycemia in newborns. It is a tremulous movement that can be observed in response to low blood glucose levels.

B. Hypertonia: Hypertonia, or increased muscle tone, is not a typical manifestation of hypoglycemia in newborns. Instead, hypoglycemia is more likely to be associated with hypotonia or limpness.

C. Abdominal distention: Abdominal distention is not a typical sign of hypoglycemia in newborns. It may be associated with other conditions, such as gastrointestinal issues, but it is not directly related to low blood glucose levels.

D. Mottling: Mottling refers to a blotchy or uneven skin color and is not a specific sign of hypoglycemia. It can be associated with various conditions, including poor circulation, but it is not a primary indicator of low blood glucose.

The correct answer is C. Continuous contraction lasting 2 min.

A. Pressure on the perineum causing the client to bear down is a common sign in the later stages of labor when the cervix is fully dilated. It is not typically a cause for immediate concern during the admission phase.

B. Expulsion of clear fluid from the vagina may be amniotic fluid, which can indicate rupture of membranes. While important to note, it is not as urgent as a prolonged contraction.

C. Continuous contraction lasting 2 min is a concerning finding and should be reported first.

A contraction lasting 2 minutes is excessively long and may lead to decreased uterine blood flow, affecting fetal oxygenation. It requires prompt attention from the healthcare provider.

D. Expulsion of a blood-tinged mucous plug, also known as the "bloody show," is a common occurrence in early labor and is not as urgent as the prolonged contraction.