A nurse in the labor unit is admitting a patient who reports experiencing painful contractions.
The nurse determines that the contractions last 1 minute and occur every 3 minutes.
The nurse records the following vital signs: fetal heart rate of 130/min, maternal heart rate of 128/min, and maternal blood pressure of 92/54 mm Hg. What is the nurse’s priority action?

Choice A rationale

Asking the partner to talk about his difficulties in caring for the client is the nurse’s priority. This intervention allows the nurse to assess the partner’s emotional state and provide appropriate support and resources.

Choice B rationale

Recommending that the partner place the client in a long-term care facility may not be the best initial intervention. The decision to place a loved one in a long-term care facility is complex and involves many factors. The nurse should first assess the partner’s needs and concerns before making such a recommendation.

Choice C rationale

Telling the partner to call a family meeting to get help may be a helpful suggestion, but it is not the nurse’s priority. The nurse should first assess the partner’s emotional state and needs before suggesting specific interventions.

Choice D rationale

Suggesting that the partner see a counselor to help him cope with his exhaustion may be a helpful intervention, but it is not the nurse’s priority. The nurse should first assess the partner’s emotional state and needs before suggesting specific interventions.

Choice A rationale

Hyperglycemia, or high blood sugar, is a condition that is most commonly seen in individuals with diabetes. Symptoms can include frequent urination, increased thirst, and increased hunger. If left untreated, it can lead to serious complications such as diabetic ketoacidosis.

Choice B rationale

Anemia is a condition characterized by a decrease in the total amount of red blood cells or hemoglobin in the blood, or a lowered ability of the blood to carry oxygen. Symptoms can include fatigue, weakness, pale or yellowish skin, irregular heartbeats, shortness of breath, dizziness or lightheadedness, and chest pain.

Choice C rationale

Type 1 diabetes mellitus is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar (glucose) to enter cells to produce energy. The far more common type 2 diabetes occurs when the body becomes resistant to insulin or doesn’t make enough insulin.

Choice D rationale

Hypertension, or high blood pressure, is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease. If the nurse is reviewing the client’s medical records and actions to be taken, it is likely that the client is experiencing hypertension.