A nurse is caring for a patient with diabetes and plans to administer regular insulin subcutaneously before breakfast at 0800.
After checking the patient’s morning glucose level, what action should the nurse take?

Choice A rationale

Having the patient void is not the immediate priority. While it is important to ensure the bladder is not distended, which could interfere with labor progress, the vital signs suggest a more urgent concern.

Choice B rationale

Asking the patient if she needs pain medication is important for comfort measures during labor, but it is not the immediate priority. The nurse’s first responsibility is to ensure the safety of the mother and baby.

Choice C rationale

Turning the patient on her side and rechecking the blood pressure is the correct action. The maternal blood pressure is low, which could indicate supine hypotensive syndrome. This occurs when the gravid uterus compresses the inferior vena cava when the woman is supine, reducing venous return to the heart. Turning the woman on her side may relieve this pressure and improve blood pressure.

Choice D rationale

Notifying the healthcare provider of the findings is important, but it is not the first action the nurse should take. The nurse should first address the mother’s hypotension by turning her on her side.

Choice A rationale

Administering the insulin 30 minutes after breakfast is not recommended. Regular insulin should be administered before meals.

Choice B rationale

Administering the insulin at 0700 is not recommended. Regular insulin should be administered 30 to 45 minutes before a meal.

Choice C rationale

Administering the insulin at 0730 is recommended if breakfast is at 0800. Regular insulin should be administered 30 to 45 minutes before a meal. This is the correct answer.

Choice D rationale

Administering the insulin when the breakfast tray arrives is not recommended. Regular insulin should be administered 30 to 45 minutes before a meal.