A nurse is assessing a client who is postpartum and has developed endometritis.
Which of the following findings should the nurse expect?

Choice A rationale

A nonstress test (NST) does not require the client to fast. The client can eat and drink normally, and sometimes a sugary beverage is even encouraged to stimulate fetal movement, as the test aims to record fetal heart rate accelerations in response to these movements.

Choice B rationale

The nonstress test is a screening tool used to assess fetal well-being by measuring the fetal heart rate's response to fetal movement. It does not provide information about genetic problems, which are typically identified through genetic testing or prenatal diagnostic procedures such as amniocentesis.

Choice C rationale

A key component of the nonstress test involves the mother noting fetal movements. The client is given a marker, often a button, to press each time she feels the baby move. This action correlates the mother's perception of movement with the fetal heart rate accelerations recorded on the monitor.

Choice D rationale

Oxytocin is not administered during a nonstress test. The purpose of this test is to assess the baby's baseline heart rate and accelerations without external stimulation. Oxytocin is used in a contraction stress test, which is a different procedure to evaluate how the baby handles uterine contractions. *.

Choice A rationale

Ketonuria, the presence of ketones in the urine, is typically associated with hyperglycemia and diabetic ketoacidosis. When glucose levels are high and cells can't use it for energy, the body starts breaking down fats, producing ketones as a byproduct. A blood glucose reading of 64 mg/dL is low and indicates hypoglycemia, not hyperglycemia.

Choice B rationale

Warm skin is a sign of vasodilation, often associated with a fever or an inflammatory response. In the context of hypoglycemia, the sympathetic nervous system is activated, leading to vasoconstriction, which would typically cause the skin to feel cool and clammy, not warm.

Choice C rationale

Nervousness is a common symptom of hypoglycemia. When blood glucose levels drop, the body releases counterregulatory hormones like epinephrine and norepinephrine from the adrenal glands. This sympathetic nervous system activation causes symptoms such as nervousness, anxiety, palpitations, and tremors as the body attempts to raise blood sugar.

Choice D rationale

Tachypnea, or rapid breathing, is a clinical finding associated with metabolic acidosis, such as diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the high acid load by increasing the respiratory rate to blow off carbon dioxide. It is not a typical symptom of hypoglycemia, which is indicated by a reading of 64 mg/dL. .