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A nurse is assisting with the care of a 24-year-old female client who was admitted to the postpartum unit.

Exhibits

Complete the following sentence by using the list of options.

The nurse should plan to (select one from each list)

then

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

The nurse should plan to:

A. Check the client's blood glucose level; then B. Implement seizure precautions

In the context of a postpartum client with type 1 diabetes, symptoms such as diaphoresis, clammy skin, rapid pulse, and feeling weak can suggest hypoglycemia, which needs to be immediately addressed. Checking the client's blood glucose level will confirm if hypoglycemia is present.

Implementing seizure precautions is necessary because severe hypoglycemia can lead to seizures, especially if it remains untreated.

  • Checking the client's blood glucose level helps identify if the client is experiencing hypoglycemia, a common complication in diabetic patients.
  • Implementing seizure precautions ensures the client's safety in case of severe hypoglycemia, which can result in neurological symptoms or seizures.

Other options such as drawing blood for culture and sensitivity are less relevant here because there are no signs of infection. Having the client drink soda is a potential action but less immediately critical compared to confirming hypoglycemia first. Administering an IV bolus of dextrose is another direct treatment for hypoglycemia, yet confirming hypoglycemia before any treatment is vital.

Checking deep tendon reflexes, obtaining a urine sample to test for ketones, and applying a warm compress to the abdomen are not immediate priorities in the context of the described symptoms.


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Related Questions

Correct Answer is []

Explanation

Endometritis is indicated by a high temperature (38.4°C), elevated heart rate (108/min), foul-smelling lochia, and a tender boggy uterus. These are classic signs of infection post-cesarean birth, particularly following prolonged rupture of membranes, which increases infection risk. Administering broad-spectrum antibiotics targets the infection, while oxytocic medication helps manage uterine atony and promote uterine contraction to expel infected lochia.

Actions Explanation:

  1. Administer broad-spectrum antibiotic medication: This addresses the underlying infection causing endometritis.
  2. Monitor the administration of an oxytocic medication: Ensures uterine contraction, reducing uterine atony and helping clear infected materials.

Parameters to Monitor:

  1. Temperature: Indicates the presence and resolution of infection.
  2. Lochia amount and odor: Helps assess the severity of infection and effectiveness of treatment.

Other Conditions:

  • B. Urinary tract infection (UTI): Less likely since the client denies urinary symptoms like burning or difficulty.
  • C. Deep vein thrombosis (DVT): Bilateral lower extremity edema without pain, warmth, or tenderness doesn't align with unilateral swelling/pain typical of DVT.
  • D. Engorgement: Not likely since the client is bottle-feeding and denies nipple discomfort; also, the lochia characteristics and boggy uterus point to infection.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

  1. Encourage frequent ambulation - Anticipated
    • Ambulation can help progress labor and is generally encouraged if there are no contraindications.
  2. Ensure the client maintains a supine position while in bed - Contraindicated
    • Supine positioning can decrease uteroplacental blood flow and is generally not recommended during labor.
  3. Check FHR every 30 min - Anticipated
    • Regular monitoring of the fetal heart rate is essential to assess fetal well-being during labor.
  4. Perform a Nitrazine test - Anticipated
    • Since the client reports a gush of fluid, a Nitrazine test can help confirm whether the membranes have ruptured.
  5. Prepare the client for catheterization - Nonessential
    • The client has voided recently and doesn’t indicate difficulty, making catheterization unnecessary at this stage.
  6. Obtain CBC blood sample - Anticipated
    • A CBC can provide important information about the client's health status and identify any potential issues, like infection or anemia.
  7. Check the client's temperature every hour - Anticipated
    • Regularly monitoring temperature can help detect signs of infection, which is particularly important if the membranes have ruptured.

Intervention

Anticipated

Nonessential

Contraindicated

Encourage frequent ambulation

✔

Ensure the client maintains a supine position while in bed

✔

Check FHR every 30 min

✔

Perform a Nitrazine test

✔

Prepare the client for catheterization

✔

Obtain CBC blood sample

✔

Check the client's temperature every hour

✔

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