A nurse is caring for a client in active labor.

Admission Assessment.

0200:. Gravida 1, Para 0 at 39 weeks gestation.

Presents with.

contractions occurring every 5 to 6 min, 45 to 60 seconds.

duration.

Cervical examination 4 cm dilated, 50% effaced.

Admit.

to the labor and delivery unit.

Nurses' Notes.

0200:. Admitted to the labor and delivery unit, and reports pain as 7 on a scale.

of O to 10 with contractions.

Cervix 4 cm dilated, 50% effaced,with membranes intact.

0230:. The client reports increasing discomfort with contractions.

Cervix 5. cm dilated, 60% effaced, with membranes intact.

Contractions.

occurring every 5 min, 45 to 60 seconds duration.

0300:. Epidural anesthesia was initiated.

Cervix 7 cm dilated, 70% effaced,. with membranes intact.

Contractions occur every 4 to 5 min,60 seconds duration.

Vital Signs.

0200:. Temperature 36.9° C (98.4° F). Heart rate 86/min.

Respiratory rate 18/min.

BP 118/78 mm Hg. 0230:. Temperature 37° C (98.6° F). Heart rate 88/min.

Respiratory rate 20/min.

BP 120/80 mm Hg. 0300:. Temperature 37.1° C (98.8° F). Heart rate 90/min.

Respiratory rate 18/min.

BP 122/76 mm Hg. The nurse is assuming care for the client at 0305.

For each nursing action, click to specify if the nursing action is essential. contraindicated for the client.

The correct answer is choice C: Initiate continuous cardiac monitoring.

Choice A rationale:

Implementing fluid restrictions is not recommended for a child with diabetic ketoacidosis (DKA). DKA is characterized by severe dehydration due to osmotic diuresis, and fluid replacement is a critical component of treatment to restore hydration and circulatory volume.

Choice B rationale:

Monitoring vital signs every 8 hours is not sufficient for a child with DKA. DKA is an acute, life-threatening condition that requires close monitoring of vital signs to detect changes in the patient’s condition promptly. Vital signs should be monitored more frequently, typically every 1 to 2 hours, depending on the severity of the DKA and institutional protocols.

Choice C rationale:

Continuous cardiac monitoring is recommended for a child with DKA. DKA can lead to serious electrolyte imbalances, such as hypokalemia, which can cause cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these potential complications.

Choice D rationale:

Administering subcutaneous insulin 30 minutes before meals is not appropriate for the acute management of DKA. In DKA, insulin is typically administered intravenously to rapidly decrease blood glucose levels and correct metabolic acidosis. Subcutaneous insulin is not used until the patient is stable and able to eat.

The correct answer is: b: Perform the procedure prior to meals.

Choice A rationale: The rationale for Choice A involves understanding the technique of percussion in postural drainage for cystic fibrosis management. Percussion is a component of chest physiotherapy that involves rhythmic clapping or tapping on the chest wall to help loosen and mobilize secretions within the airways. However, holding the hand flat during percussion may not effectively transmit the necessary force to the chest wall for optimal secretion mobilization. Instead, cupping the hands allows for better resonance and transmission of percussion force, enhancing the effectiveness of the procedure.

Choice B rationale: Performing postural drainage prior to meals is the recommended timing for several reasons. Firstly, initiating the procedure before meals allows the child's stomach to be relatively empty, reducing the risk of discomfort, nausea, or vomiting during the procedure. Secondly, performing postural drainage before meals helps prevent aspiration of stomach contents, which can occur if the child vomits during or after the procedure. Aspiration poses significant risks, including lung infection and respiratory distress, particularly in individuals with compromised respiratory function such as those with cystic fibrosis.

Choice C rationale: While bronchodilators may play a role in managing airway obstruction in cystic fibrosis, administering them after postural drainage is not a standard practice. Bronchodilators are typically used to alleviate bronchoconstriction and improve airflow in the lungs. However, their administration after postural drainage may not be directly related to the immediate goals of the procedure, which are to mobilize and clear pulmonary secretions. The timing of bronchodilator administration is often guided by the individual's clinical condition and the presence of symptoms such as wheezing or shortness of breath.

Choice D rationale: Performing postural drainage twice daily may not provide adequate frequency for managing secretions in individuals with cystic fibrosis. The goal of postural drainage is to facilitate the removal of thick, tenacious mucus from the airways to improve respiratory function and reduce the risk of complications such as infections. In cystic fibrosis, mucus clearance is essential for maintaining pulmonary health and preventing exacerbations. Therefore, a more frequent regimen, often including multiple sessions of postural drainage per day, may be necessary to achieve optimal therapeutic outcomes and prevent mucus accumulation and airway obstruction.