A nurse is assisting with the admission of a client to the labor and delivery unit.

Exhibits

Which of the following actions should the nurse recommend including in the client's plan of care? For each potential recommendation, click to specify if the recommendation is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

A. "Anticipate that the insulin glargine will peak in 3 hours." Insulin glargine is a long-acting basal insulin with no pronounced peak. Instead, it provides a steady level of insulin over 24 hours, reducing the risk of hypoglycemia. Unlike short- or intermediate-acting insulins, it does not have a defined peak time.
B. "Draw up the insulin lispro and insulin glargine in separate syringes." Insulin glargine should never be mixed with other insulins in the same syringe, as it has a unique pH that can cause precipitation when combined. Insulin lispro, a rapid-acting insulin, can be mixed with some other insulins, but it must be drawn up separately from insulin glargine to maintain its stability and effectiveness.
C. "Expect insulin glargine to be cloudy." Insulin glargine is a clear solution. Cloudy insulins, such as NPH (neutral protamine Hagedorn), require gentle rolling before administration to mix the suspension evenly. If insulin glargine appears cloudy, it may be contaminated or compromised and should not be used.
D. "Take an extra dose of insulin lispro prior to aerobic exercise." Taking extra insulin lispro before exercise can increase the risk of hypoglycemia, as physical activity naturally lowers blood glucose levels. Clients with diabetes should monitor their blood glucose before, during, and after exercise and may need to adjust their carbohydrate intake rather than taking additional insulin.

A. "An incident report has been completed and sent to risk management." Incident reports are used for internal facility documentation and quality improvement but should not be mentioned in the medical record. Including this information could make the report discoverable in legal proceedings, which is why it should remain separate from the client’s medical documentation.
B. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement assigns blame without objective evidence and does not follow factual documentation principles. Medical records should include observable data, client statements, and assessments rather than subjective conclusions or assumptions about the cause of the fall.
C. "Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom.'" Including the client's direct statement ensures accurate, objective documentation. It provides firsthand information about the incident without making assumptions or assigning blame. Client statements should always be documented using quotation marks to maintain accuracy.
D. "The client does not appear to have any injuries resulting from the fall." This statement is subjective and may be misleading. A client could have internal injuries that are not immediately visible. Instead, the nurse should document a detailed physical assessment, such as "No visible injuries noted. Client denies pain or discomfort at this time."