A nurse is assessing the lifestyle practices of a pregnant client.
Which of the following lifestyle factors indicates an increased risk for high-risk pregnancy?

Choice A rationale

Temperature instability, particularly hypothermia, is a significant indicator of neonatal hypoglycemia. Glucose is the primary metabolic fuel for thermogenesis, and its deficiency impairs the infant's ability to maintain core body temperature. The normal newborn temperature range is typically 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice B rationale

Acrocyanosis, a bluish discoloration of the hands and feet, is a common and usually benign finding in newborns, especially in the first 24-48 hours, due to immature peripheral circulation. It does not directly indicate hypoglycemia; rather, it reflects normal physiological adaptation to extrauterine life.

Choice C rationale

Jitteriness, or tremors, is a classic neurological sign of hypoglycemia in newborns. The central nervous system is highly dependent on glucose for energy, and insufficient glucose supply can lead to neuronal excitability and involuntary muscle movements. This is often an early and prominent symptom.

Choice D rationale

Hypotonia, characterized by decreased muscle tone and floppiness, can be a symptom of severe or prolonged hypoglycemia. Glucose is essential for proper neuromuscular function, and its deprivation can impair nerve impulse transmission and muscle contraction, leading to reduced muscle resistance to passive movement.

Choice E rationale

Abdominal distention is typically associated with gastrointestinal issues such as feeding intolerance, bowel obstruction, or necrotizing enterocolitis. It is not a direct or common manifestation of hypoglycemia in newborns. Hypoglycemia primarily affects metabolic and neurological systems.

Choice A rationale

While monitoring vital signs (temperature, heart rate, and blood pressure) is important for overall maternal assessment, in the context of strong contractions and reported nausea/urge to defecate, these specific vital signs are not the immediate priority for identifying the most critical complication. Normal temperature is 36.5-37.5°C, heart rate 60-100 bpm, blood pressure 90/60 to 120/80 mmHg.

Choice B rationale

The client's symptoms (strong contraction, nausea, urge to defecate) strongly suggest the second stage of labor, specifically an urge to push. The highest priority is to determine the fetal heart rate in relationship to the contraction, as this immediate assessment evaluates fetal well-being and detects potential distress, like late decelerations, indicating uteroplacental insufficiency.

Choice C rationale

Examining vaginal discharge for meconium is important if there are signs of fetal distress, but assessing the fetal heart rate pattern in relation to contractions directly provides real-time information about fetal oxygenation and is therefore the immediate priority when assessing labor progress with these symptoms.

Choice D rationale

Performing a vaginal examination to assess labor progress is a crucial step to confirm cervical dilation and fetal descent. However, before internal examination, ensuring fetal well-being through external monitoring of the fetal heart rate during contractions is paramount, especially with the client's reported symptoms suggesting advanced labor.