A nurse is assisting with the care of a 24-year-old female client who was admitted to the postpartum unit.
Complete the following sentence by using the list of options.
The nurse should plan to (select one from each list)
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","F","G"]
Explanation
Choice A rationale:
Deep tendon reflexes of 1+ are considered normal for a postpartum client and do not typically require immediate follow-up. They indicate slight but definite muscle contraction with reinforcement.
Choice B rationale:
Lateral deviation of the uterus can indicate bladder distension, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. Immediate follow-up is necessary to address this issue.
Choice C rationale:
A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client and does not require immediate follow-up unless there are other symptoms of preeclampsia or hypertension.
Choice D rationale:
A pain rating of 3 on a scale of 0 to 10 is mild and is expected in the postpartum period. It does not require immediate follow-up unless the pain is severe or unrelieved.
Choice E rationale:
Soft breasts in the immediate postpartum period are normal as milk production has not yet fully begun. This does not require immediate follow-up.
Choice F rationale:
A soft uterine tone indicates uterine atony, which can lead to postpartum hemorrhage. This requires immediate follow-up and intervention to ensure the uterus is contracting properly.
Choice G rationale:
A large amount of lochia rubra can be a sign of postpartum hemorrhage. Immediate follow-up is necessary to assess and manage bleeding.
Choice H rationale:
Peripheral edema of 2+ in the bilateral lower extremities is common in postpartum clients due to fluid shifts and does not typically require immediate follow-up unless accompanied by other concerning symptoms.
Correct Answer is C
Explanation
Choice A rationale
Maternal age of 21 years is not considered a significant risk factor for gestational diabetes. Typically, advanced maternal age (35 years or older) is considered a risk factor due to changes in insulin resistance that occur with age.
Choice B rationale
A fasting blood glucose of 72 mg/dL is within the normal range and does not indicate a risk for gestational diabetes. Gestational diabetes is usually diagnosed with fasting blood glucose levels higher than 95 mg/dL.
Choice C rationale
Previous newborn weighing 4.8 kg is a significant risk factor for gestational diabetes. Having a macrosomic (large) baby in a previous pregnancy is linked with an increased risk of developing gestational diabetes in subsequent pregnancies.
Choice D rationale
A prepregnancy BMI of 23 is within the normal range (18.5-24.9) and does not increase the risk of gestational diabetes. Higher BMI levels, particularly above 25, are associated with an increased risk.
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