A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

Assess the fetal heart rate pattern.

Choice B rationale:

When a laboring client's membranes have just ruptured, the nurse's next action should be to assess the fetal heart rate pattern. Rupture of membranes can lead to changes in amniotic fluid, which can affect the fetal environment and potentially cause fetal distress. By assessing the fetal heart rate pattern, the nurse can determine if the baby is tolerating the labor process well or if there are signs of fetal compromise that require further intervention.

Choice A rationale:

While assessing the client's blood pressure (Choice A) is important during labor, it is not the immediate next action when the membranes have ruptured.

Choice C rationale:

Taking the client's temperature (Choice C) is also important, but it is not the priority action when the membranes have ruptured.

Choice D rationale:

Preparing for a c-section (Choice D) is not the initial action unless there are specific indications for an emergency cesarean section. Assessing the fetal heart rate is more critical at this stage.

Choice A rationale:

Hypertonia (increased muscle tone) is not a manifestation of hypoglycemia in a newborn. Instead, hypotonia (decreased muscle tone) is more characteristic.

Choice B rationale:

This is the correct choice. Jitteriness is a common sign of hypoglycemia in a newborn. It may be accompanied by other symptoms like poor feeding, tremors, and irritability.

Choice C rationale:

Acrocyanosis (bluish discoloration of the hands and feet) is a normal finding in newborns and is not specifically associated with hypoglycemia.

Choice D rationale:

Generalized petechiae (small red or purple spots on the skin caused by bleeding under the skin) are not indicative of hypoglycemia but may be associated with other medical conditions.