Choice A rationale:

Ask the mother if any visitors were expected to arrive. Rationale: While it is essential to gather information from the mother, such as whether any visitors were expected, this action does not address the immediate concern of a potentially missing newborn. Matching ID bands is a critical first step in ensuring the safety and security of all infants and mothers on the unit.

Choice B rationale:

Match ID bands of all infants and mothers on the unit. Rationale: This is the correct answer. In a situation where a new mother believes her infant is missing, the nurse's priority is to ensure the safety and security of all infants and mothers. Matching ID bands can help confirm the identity of each infant and mother and prevent any potential mix-ups or missing infants.

Choice C rationale:

Determine if the newborn is in the nursery. Rationale: While it is essential to check the nursery to determine if the newborn is there, it should not be the first action taken. Matching ID bands of all infants and mothers is a more immediate and comprehensive approach to ensuring the safety and security of all patients on the unit.

Choice D rationale:

Activate the lockdown procedure. Rationale: Activating the lockdown procedure should only be done in situations where there is a security threat or immediate danger to the safety of patients and staff. In this case, the primary concern is not a security threat but rather the potential misplacement of an infant. Matching ID bands and confirming the whereabouts of all infants and mothers are more appropriate initial actions.

Choice A rationale:
Starting an insulin drip at 0.1 u/kg/hr is a common treatment for diabetic ketoacidosis (DKA). The goal is to lower blood glucose levels while avoiding a rapid decrease that could lead to cerebral edema. Insulin infusions allow for precise control of the rate and can be adjusted as needed based on the patient’s response.
Choice B rationale:
Giving a long-acting insulin dose is not typically done during the acute treatment of DKA. The patient has already taken a dose of insulin glargine at home. Additional doses of long-acting insulin could potentially lead to hypoglycemia.
Choice C rationale:
Providing an oral medication that enhances insulin production would not be beneficial in this case. The patient has type 1 diabetes, which means her body does not produce insulin. Therefore, medications that stimulate insulin production would not be effective.
Choice D rationale:
Changing the intravenous fluid to 5% dextrose and 0.45% sodium chloride with 20 mEq potassium can help prevent hypoglycemia and hypokalemia, which are potential complications of DKA treatment. As blood glucose levels decrease with treatment, dextrose can help maintain appropriate glucose levels. Potassium is often depleted in DKA and needs to be replaced.
Choice E rationale:
Having the client drink as much as they can tolerate would not be appropriate at this time. The patient is currently experiencing nausea and vomiting, which could be exacerbated by oral fluid intake. Additionally, she is NPO (nothing by mouth), likely due to her unstable condition.
Choice F rationale:
Giving 1 L of 0.9% sodium chloride IV can help correct dehydration, which is common in DKA due to excessive urination caused by high blood glucose levels.
Choice G rationale:
Promoting the removal of electrolytes with a diuretic would not be beneficial in this case. The patient is likely already dehydrated and may have electrolyte imbalances due to DKA. Using a diuretic could exacerbate these issues.
Choice H rationale:
Giving a multivitamin is not typically part of the acute treatment for DKA. While overall nutritional status is important in managing diabetes, it would not address the immediate concerns of hyperglycemia and acidosis in DKA.
Choice I rationale:
Replacing potassium as needed is crucial in the treatment of DKA. Potassium levels can drop rapidly during treatment as insulin allows potassium to move back into cells. Low potassium (hypokalemia) can cause dangerous heart rhythms and muscle weakness.