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A nurse is assisting with the care of a 24-year-old female client who was admitted to the postpartum unit.

Exhibits

Complete the following sentence by using the list of options.

The nurse should plan to (select one from each list)

then

Answer and Explanation

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.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

  1. Encourage frequent ambulation - Anticipated
    • Ambulation can help progress labor and is generally encouraged if there are no contraindications.
  2. Ensure the client maintains a supine position while in bed - Contraindicated
    • Supine positioning can decrease uteroplacental blood flow and is generally not recommended during labor.
  3. Check FHR every 30 min - Anticipated
    • Regular monitoring of the fetal heart rate is essential to assess fetal well-being during labor.
  4. Perform a Nitrazine test - Anticipated
    • Since the client reports a gush of fluid, a Nitrazine test can help confirm whether the membranes have ruptured.
  5. Prepare the client for catheterization - Nonessential
    • The client has voided recently and doesn’t indicate difficulty, making catheterization unnecessary at this stage.
  6. Obtain CBC blood sample - Anticipated
    • A CBC can provide important information about the client's health status and identify any potential issues, like infection or anemia.
  7. Check the client's temperature every hour - Anticipated
    • Regularly monitoring temperature can help detect signs of infection, which is particularly important if the membranes have ruptured.

Intervention

Anticipated

Nonessential

Contraindicated

Encourage frequent ambulation

✔

Ensure the client maintains a supine position while in bed

✔

Check FHR every 30 min

✔

Perform a Nitrazine test

✔

Prepare the client for catheterization

✔

Obtain CBC blood sample

✔

Check the client's temperature every hour

✔

Correct Answer is D

Explanation

Choice A rationale

Remaining in the sitz bath for only 10 minutes might not provide enough relief for a postpartum client with an episiotomy and hemorrhoids. Extended periods in a sitz bath can help reduce pain and promote healing.

Choice B rationale

Using numbing spray before cleansing is helpful for pain management, but it is not as beneficial as other methods for reducing inflammation and promoting healing.

Choice C rationale

Placing a heat pack to the area several times a day can help with pain but might not be as effective as other options in reducing swelling and promoting healing of hemorrhoids and episiotomy sites.

Choice D rationale

Applying witch hazel pads after urination helps reduce swelling, provides soothing relief, and promotes healing for both hemorrhoids and episiotomy sites. Witch hazel has natural astringent properties that are beneficial for postpartum perineal care.

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