A nurse is assisting with the care of a 24-year-old female client who was admitted to the postpartum unit.
Complete the following sentence by using the list of options.
The nurse should plan to (select one from each list)
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
"Decreased BP.”. This is correct because hyperemesis gravidarum can lead to dehydration, which in turn can cause hypotension (decreased blood pressure).
Choice B rationale
"WBC count 15,000/mm³ (5,000 to 15,000/mm³).”. This is incorrect because while WBC count can be elevated due to stress or infection, it is not a primary manifestation of hyperemesis gravidarum.
Choice C rationale
"Pruritus.”. This is incorrect because pruritus is not commonly associated with hyperemesis gravidarum. It is more likely related to other conditions like cholestasis of pregnancy.
Choice D rationale
"Hemoglobin 18 g/dL (11 to 16 g/dL).”. This is incorrect because an elevated hemoglobin level is not a direct manifestation of hyperemesis gravidarum, although dehydration can potentially concentrate blood components and slightly elevate hemoglobin.
Correct Answer is D
Explanation
Choice A rationale
Inserting the suppository 5 cm is generally insufficient for proper placement. The suppository needs to be placed further along the vaginal canal to be effective.
Choice B rationale
Applying petroleum jelly to the suppository is not recommended because it can interfere with the absorption and effectiveness of the medication.
Choice C rationale
Assisting the client into a prone position is not appropriate for inserting a vaginal suppository. The client should be in a lithotomy or supine position with legs bent.
Choice D rationale
Inserting the suppository along the posterior vaginal wall ensures proper placement and maximizes the effectiveness of the medication by allowing it to dissolve and be absorbed where it is needed.
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