A nurse is caring for a patient receiving epidural analgesia for pain during labor. Which of the following observations should be the nurse’s priority?

Choice A rationale

Phosphate levels are not directly affected by spironolactone. Spironolactone is a potassium- sparing diuretic and does not typically affect phosphate levels.

Choice B rationale

Decreased potassium level is not typically expected in a patient taking spironolactone. Spironolactone is a potassium-sparing diuretic, meaning it can actually lead to increased potassium levels. However, in the context of liver failure and ascites, other factors may influence potassium levels.

Choice C rationale

Chloride levels are not directly affected by spironolactone. Spironolactone primarily affects the balance of potassium and sodium in the body.

Choice D rationale

Sodium levels could potentially be decreased in a patient taking spironolactone, as it can cause the body to lose sodium. However, in the context of liver failure and ascites, sodium levels are often carefully managed.

Choice A rationale:

Administering a bolus of IV fluids in this scenario addresses potential dehydration, which is crucial given the client’s dry mucous membranes and elevated blood glucose levels. The client’s symptoms—fatigue, blurred vision, dizziness, and headache—are consistent with possible hyperglycemia and dehydration. In diabetic patients, high blood glucose levels can lead to osmotic diuresis, causing excessive fluid loss and dehydration. The client's financial constraints have led to an inadequate supply of glucose strips and insulin, which exacerbates the risk of dehydration. The warm, dry skin and slightly dry mucous membranes observed further suggest a

state of dehydration. Administering IV fluids helps rehydrate the client and can improve overall symptoms by restoring fluid balance and supporting better glucose management.

Choice B rationale:

Administering insulin could be a necessary intervention for managing elevated blood glucose levels. However, given that the client’s primary issue appears to be dehydration rather than hyperglycemia alone, addressing hydration first with IV fluids is a more immediate priority. Insulin administration alone might not address the potential underlying dehydration and could lead to complications if fluid status is not corrected. Therefore, while insulin will eventually need to be adjusted (as indicated by the provider’s prescription to increase the glargine dose), it is secondary to the need for rehydration.

Choice C rationale:

Administering oxygen therapy at 2 L/min via nasal cannula is generally reserved for patients with respiratory distress or hypoxemia. The client’s respiratory rate and oxygen saturation are within normal limits, and there is no indication of respiratory distress or abnormal breath sounds. The symptoms described—fatigue, dizziness, and blurred vision—are more aligned with dehydration and hyperglycemia rather than a need for supplemental oxygen. Therefore, oxygen therapy is not the priority in this case.

Choice D rationale:

Placing the client on fall precautions and providing a bedside commode is important, particularly given the client's dizziness and anxiety about potential falls. However, fall precautions are more of a supportive measure rather than a direct intervention to address the immediate medical needs presented. The primary concern in this scenario is the client's dehydration and elevated blood glucose levels. While fall precautions are necessary for safety, they do not address the underlying issue of dehydration and its associated symptoms. The immediate priority should be to correct the fluid imbalance before implementing additional safety measures.