A nurse is caring for a client in labor at 39 weeks of gestation.
Which of the following assessment findings requires follow-up?

The client most likely has umbilical cord compression, as evidenced by the presence of variable decelerations in fetal heart rate (FHR) and uterine tenderness. Umbilical cord compression is the most plausible condition given the symptoms and clinical indicators. Variable decelerations in FHR often indicate transient umbilical cord compression. Uterine tenderness can be associated with positional changes that exacerbate compression. These findings necessitate immediate intervention to improve fetal oxygenation and monitor ongoing fetal well-being.

Parameters:

• Variable decelerations in FHR: Indicate intermittent cord compression, leading to changes in fetal oxygenation, necessitating continuous monitoring.
• Uterine tenderness: Suggests possible positional issues or complications related to compression, requiring careful assessment to ensure optimal fetal and maternal health.

Actions:

• Change client position: Positional changes can relieve pressure on the umbilical cord, improving fetal oxygenation.
• Initiate continuous fetal monitoring: Essential to assess the ongoing status of fetal heart rate and detect any further decelerations or complications promptly.

Other Conditions:

• Dysfunctional labor: Typically associated with abnormal progression of labor, not directly indicated by variable decelerations or uterine tenderness alone.
• Placental abruption: Characterized by painful bleeding and abdominal pain, not suggested by the provided data.
• Pre-eclampsia: Marked by high blood pressure and proteinuria, absent in this case.

Choice A rationale

Monitoring the newborn's blood pressure does not directly address symptoms like diaphoresis, jitteriness, and lethargy. These symptoms indicate an immediate need to check blood glucose levels for hypoglycemia.

Choice B rationale

Obtaining blood glucose by heel stick is the correct step because diaphoresis, jitteriness, and lethargy in a newborn are classic signs of hypoglycemia. Timely detection and correction of blood glucose levels are critical.

Choice C rationale

Placing the newborn in a radiant warmer might help maintain body temperature but does not address the root cause of the symptoms, which is likely hypoglycemia.

Choice D rationale

Initiating phototherapy is used to treat jaundice (high bilirubin levels) and is not indicated for managing symptoms of hypoglycemia like diaphoresis, jitteriness, and lethargy.