A nurse is caring for a client who has an ectopic pregnancy. Which of the following findings should the nurse expect?

Rationale:
A. Hold the sterile package in his dominant hand and open the top flap of the package toward his body: The top flap should be opened away from the nurse’s body to avoid reaching over and contaminating the sterile field. Opening toward the body risks touching or dropping contaminants onto the field.

B. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Sterile items should be dropped from a minimal height, close to the field, to prevent them from bouncing, falling off, or becoming contaminated. A 10-inch drop increases the risk of contamination.

C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 1 inch (2.5 cm) of a sterile field is considered contaminated, not just 0.5 inches. Placing objects inside only 0.5 in does not guarantee sterility and may result in contamination.

D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: Keeping the bottle outside the sterile field prevents contamination from the outside of the bottle. Only the sterile contents should enter the sterile container, maintaining the integrity of the sterile field during the dressing change.

Rationale:
A. Acetone breath odor: A fruity or acetone breath odor occurs when the body produces ketones due to fat breakdown in hyperglycemia or diabetic ketoacidosis (DKA). This finding is not associated with hypoglycemia but rather prolonged high blood glucose levels.

B. Polydipsia: Excessive thirst (polydipsia) is a sign of hyperglycemia because the kidneys attempt to excrete excess glucose, leading to dehydration. It does not occur during hypoglycemia, when blood sugar levels are abnormally low.

C. Inability to concentrate: Low blood glucose deprives the brain of its primary energy source, leading to confusion, irritability, and difficulty concentrating. These neuroglycopenic symptoms are hallmark signs of hypoglycemia and can progress to altered consciousness if untreated.

D. Diaphoresis: Sweating is a classic adrenergic response to hypoglycemia as the body releases epinephrine to raise blood glucose levels. It serves as an early warning sign, prompting immediate carbohydrate intake to prevent further decline in blood sugar.

E. Tremors: Tremors occur due to increased sympathetic nervous system activity during hypoglycemia. The body responds to falling glucose by releasing catecholamines, which stimulate muscle activity and cause shaking or trembling sensations.