A nurse is caring for a 24-year-old female client in the postpartum unit. The client has a history of type 1 diabetes mellitus, first diagnosed at 14 years of age, and is on insulin for diabetes management. The client is gravida 1 para 1 following a spontaneous vaginal birth at 37 weeks of gestation. The newborn was large for gestational age, weighing 4.1 kg (9 lb). The client has a third-degree laceration that required several stitches.
Drag words from the choices below to fill in each blank in the following sentence.
Sentence: The nurse should plan to
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
The nurse should plan to B. check the client’s blood glucose level and A. obtain a urine sample to test for ketones.
Explanation:
- Check the client’s blood glucose level: Given the client’s history of type 1 diabetes mellitus and her current symptoms (diaphoresis, clammy skin, headache, nausea, and weakness), it is crucial to check her blood glucose level to rule out hypoglycemia or hyperglycemia, despite the recent blood glucose reading of 120 mg/dL.
- Obtain a urine sample to test for ketones: Testing for ketones is important in diabetic patients, especially when they present with symptoms that could indicate diabetic ketoacidosis (DKA), such as nausea, weakness, and a history of type 1 diabetes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Taking a break and walking at least once every hour during long trips helps improve circulation and reduces the risk of blood clots, which is particularly important during pregnancy.
Choice B rationale
Wearing the shoulder harness snug across the stomach is incorrect. The shoulder harness should be worn across the chest and between the breasts to avoid pressure on the abdomen.
Choice C rationale
Positioning the lap belt across the navel is incorrect. The lap belt should be placed under the belly, across the hips and pelvic bone, to avoid pressure on the uterus.
Choice D rationale
Moving the car seat forward, close to the steering wheel, is not recommended. Pregnant women should maintain a safe distance from the steering wheel to avoid injury in case of an accident.
Correct Answer is A
Explanation
Choice A rationale
Placing the retainer clip at the level of the baby’s armpits is the correct position for the clip. This ensures that the harness straps are positioned correctly over the baby’s shoulders, providing optimal protection in the event of a crash.
Choice B rationale
Placing the baby in the car seat at a 90-degree angle is incorrect. Newborns should be placed in a rear-facing car seat at an angle of approximately 45 degrees to ensure their airway remains open and to provide proper support for their head and neck.
Choice C rationale
Turning the car seat to face forward when the baby weighs 15 pounds is not recommended. Babies should remain in a rear-facing car seat until they reach the maximum weight or height limit specified by the car seat manufacturer, typically around 2 years of age.
Choice D rationale
Placing a thick, soft pad behind the baby’s back is not recommended. Additional padding can interfere with the proper fit of the harness and reduce the effectiveness of the car seat in protecting the baby during a crash.
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