A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a "natural" delivery.

Which action is most important for the nurse to implement?

Choice A rationale:

Correcting electrolytes that are out of normal range is a crucial goal of therapy for this client. In diabetic ketoacidosis (DKA), the body’s cells are unable to use glucose for energy due to a lack of insulin. This leads to the breakdown of fat for energy, producing ketones as a by-product. Ketones are acidic and can cause the blood’s pH to decrease, leading to metabolic acidosis. This process also leads to an increased production and excretion of electrolytes such as potassium and sodium. Therefore, correcting these electrolyte imbalances is a key goal of therapy.

Choice B rationale:

While promoting oxygenation to tissues is generally important in critical care, it is not a specific goal in the management of DKA. The primary issues in DKA are metabolic in nature, including hyperglycemia, ketosis, and acidosis.

Choice C rationale:

Preventing hyperventilation is not a specific goal in the management of DKA. Hyperventilation in DKA is a compensatory mechanism for metabolic acidosis (Kussmaul breathing). The body tries to expel more carbon dioxide to reduce the acidity of the blood.

Choice D rationale:

Reversing dehydration is another important goal of therapy for this client. In DKA, high blood glucose levels lead to osmotic diuresis, where water is drawn into the urine from the blood, leading to dehydration. This can cause hypotension and reduced tissue perfusion. Therefore, reversing dehydration through fluid replacement is a key part of treatment.

Choice E rationale:

Replacing insulin is a fundamental goal of therapy for this client. Insulin deficiency is the primary cause of DKA. Insulin allows glucose to enter cells where it can be used for energy, preventing the breakdown of fat for energy and the subsequent production of ketones.

Choice F rationale:

Providing respiratory support may be necessary in severe cases of DKA where the patient’s compensatory respiratory efforts are insufficient to maintain adequate gas exchange. However, it is not one of the primary goals of therapy in DKA management.

The correct answer is choice B. “You seem quite frightened right now.”.

Choice A rationale:

While reassuring the client that no one will hurt them is well-intentioned, it may not effectively address the client’s immediate emotional state or validate their feelings.

Choice B rationale:

Acknowledging the client’s fear helps validate their emotions and opens a pathway for further therapeutic communication. It shows empathy and understanding, which can help build trust and provide comfort.

Choice C rationale:

Telling the client they are in a safe place is reassuring, but it may not fully address the client’s immediate emotional distress or validate their feelings.

Choice D rationale:

Asking the client what they would like the nurse to do to protect them might reinforce the delusion and could potentially escalate the situation. It is more effective to acknowledge the client’s feelings and provide reassurance.