A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.)

In the context of a client at 32 weeks of gestation with complete placenta previa, the following assessment findings require immediate follow-up:

A. Fetal heart rate:

Explanation: An elevated fetal heart rate (174/min) may be indicative of fetal distress. This finding requires immediate follow-up to assess the well-being of the fetus.

F. Vaginal bleeding:

Explanation: A moderate amount of bright red vaginal bleeding is a concerning sign, especially in the context of complete placenta previa. It indicates active bleeding, and immediate follow-up is necessary to assess the severity of the situation and the well-being of both the mother and the fetus.

C & D. Hemoglobin (Hgb) and Hematocrit (Hct):

Explanation: Hemoglobin and hematocrit levels are important indicators of blood loss. Given the vaginal bleeding, these values need immediate follow-up to assess the extent of maternal blood loss and the potential need for blood transfusion.

The following assessment findings do not require immediate follow-up in the given context:

B. Fundal height:

Explanation: Fundal height (33cm) is typically measured to assess fetal growth. While it's important to monitor, it may not be an immediate concern unless there are other signs of fetal distress.

E. Platelet count:

Explanation: While platelet count is important, it may not require immediate follow-up unless there is evidence of severe bleeding and a potential risk of disseminated intravascular coagulation (DIC). In this scenario, attention to Hgb and Hct is more urgent.

G & H. White Blood Cell (WBC) count and Red Blood Cell (RBC) count:

Explanation: WBC count and RBC count may be monitored but do not require immediate follow-up unless there are signs of infection or other complications not evident in the given information.

A. Intense contractions lasting 45 to 60 seconds: Intense contractions within a normal duration are typical during the active phase of labor. This finding does not necessarily warrant immediate reassessment but rather ongoing monitoring.

B. A sense of excitement and warm, flushed skin: A sense of excitement and warm, flushed skin may be associated with the transition phase of labor and is not necessarily a cause for immediate concern.

C. An urge to have a bowel movement during contractions: This is the correct answer. The urge to have a bowel movement may indicate fetal descent and the need to assess for full cervical dilation. It could signal the need for imminent delivery, and the nurse should promptly assess the client's cervix and notify the healthcare provider.

D. Progressive sacral discomfort during contractions: Discomfort, including sacral discomfort, is common during labor. Progressive sacral discomfort may be associated with the normal progression of labor and is not a reason for immediate reassessment.