A nurse is caring for a 24-year-old female client in the postpartum unit. The client has a history of type 1 diabetes mellitus, first diagnosed at 14 years of age, and is on insulin for diabetes management. The client is gravida 1 para 1 following a spontaneous vaginal birth at 37 weeks of gestation. The newborn was large for gestational age, weighing 4.1 kg (9 lb). The client has a third-degree laceration that required several stitches.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

Sentence: The nurse should plan to

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and

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.

Choice A rationale

The statement about the partner wanting to help but not planning for the baby indicates a lack of acceptance and preparation for the pregnancy. It suggests that the adolescent and their partner may not have fully embraced the reality of the pregnancy.

Choice B rationale

Missing soda but acknowledging that it is better for the baby indicates that the adolescent is making sacrifices and changes for the benefit of the baby. This behavior reflects acceptance of the pregnancy and a willingness to prioritize the baby’s health.

Choice C rationale

Being upset about having to quit school when the baby comes indicates that the adolescent is struggling with the impact of the pregnancy on their life plans. This statement suggests a lack of acceptance and difficulty in adjusting to the pregnancy.

Choice D rationale

Expecting the parents to raise the baby due to being young indicates a lack of acceptance and responsibility for the pregnancy. It suggests that the adolescent may not be fully prepared to take on the role of a parent.

Choice A rationale

Applying lotion to the newborn’s extremities every 8 hours is not recommended during phototherapy. Lotions and ointments can cause burns when exposed to phototherapy lights and may interfere with the treatment’s effectiveness.

Choice B rationale

Repositioning the newborn every 4 hours is not frequent enough. The newborn should be repositioned every 2 hours to ensure even exposure to the phototherapy light and to prevent pressure sores.

Choice C rationale

Removing the eye mask during feedings is correct. The eye mask should be removed during feedings to allow for bonding and to check for any signs of irritation or infection. This also ensures that the newborn’s eyes are protected from the phototherapy light when not under the lamp.

Choice D rationale

Supplementing feedings with glucose water is not recommended. Breast milk or formula should be used to ensure the newborn receives adequate nutrition and hydration. Glucose water does not provide the necessary nutrients and can interfere with breastfeeding.