The nurse considers the client's initial presentation as well as the history and physical.
Draw from Word Choices to complete the sentence(s).
The nurse recognizes that the client findings of
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D","dropdown-group-3":"D"}
Postpartum hyperglycemia in a client with a history of poorly controlled gestational diabetes requires vigilant monitoring for metabolic decompensation. The transition from intrauterine to extrauterine physiology, combined with insulin resistance changes after placental delivery, can lead to acute elevations in serum glucose and osmotic diuresis, potentially signaling the onset of diabetic ketoacidosis or significant glycemic instability.
Rationale for correct choices:
- Warm, flushed skin. In the context of hyperglycemia, flushed skin often indicates vasodilation as the body attempts to manage metabolic stress or potential dehydration. While the client is also receiving oxytocin, the combination of this skin finding with a history of a high HbA1C suggests a need to rule out hyperglycemic states. The nurse must assess for concurrent signs of ketoacidosis or infection in this high-risk postpartum client.
- Polydipsia. The client's report of being extremely thirsty is a classic sign of osmotic diuresis caused by elevated blood glucose levels. High glucose concentrations in the blood pull water from the intracellular space, triggering the brain's thirst center to compensate for perceived dehydration. This finding is particularly concerning given her history of insulin-dependent gestational diabetes and an admission HbA1C of 11.4%.
- Urine output. A recorded output of 400 mL within a short window at 2230, following an initial 500 mL post-delivery (at 2100), may indicate polyuria. Combined with extreme thirst, this suggests the kidneys are attempting to excrete excess glucose, leading to significant fluid loss. The nurse must monitor for dehydration and electrolyte imbalances, as this pattern often precedes more severe metabolic crises in diabetic patients.
Rationale for incorrect choices:
- Moderate lochia. This is an expected finding in the immediate postpartum period for a G1P1 client and does not require immediate follow-up unless the volume increases or the fundus becomes boggy. Moderate lochia rubra is normal for the first two hours post-delivery. The estimated blood loss of 300 mL was also within the normal range for a vaginal birth.
- Blood loss. The client’s estimated blood loss was 300 mL, which is well below the threshold for postpartum hemorrhage (typically > 500 mL for vaginal delivery). Her initial vital signs, including a blood pressure of 130/78 and a heart rate of 72, indicate hemodynamic stability. Therefore, this specific volume is a reassuring finding rather than a priority for urgent clinical intervention.
- Weight loss. While weight changes are monitored during pregnancy and postpartum, acute weight loss is not a primary concern in the first 90 minutes after delivery. The focus during the fourth stage of labor is on fundal tone, lochia flow, and metabolic stability. Any weight change noted shortly after birth is largely attributed to the delivery of the fetus, placenta, and amniotic fluid.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Brief introduction:
Continuity of care relies on consistent provider-patient relationships to improve clinical outcomes and safety. Healthcare staffing models significantly impact care coordination and the therapeutic alliance. Establishing stability in personnel assignments reduces handover errors and ensures that nurses remain familiar with the evolving pathophysiological status of their specific patient populations.
Rationale:
A. Variable staffing involves adjusting personnel numbers based on fluctuating patient census or acuity levels. While this model optimizes fiscal efficiency, it often results in frequent floating or reassignment of nurses to different units. This unpredictability disrupts the longitudinal tracking of patient progress and prevents consistent nurse-patient bonding across a shift.
B. Rotating shifts require nursing staff to cycle through days, evenings, and nights on a regular basis. This staffing method is associated with circadian disruption and increased fatigue, which can lead to clinical errors. It hampers the nurse's ability to provide consistent follow-up on care plans that are specifically designed for different times of the day.
C. Permanent shifts are the most effective method for promoting staff stability and care continuity. When nurses work fixed hours, they are more likely to care for the same group of patients consistently over multiple days. This familiarity allows for better detection of subtle changes in patient condition and strengthens the overall therapeutic relationship.
D. Block scheduling involves assigning staff to work a set number of consecutive days followed by a set number of days off. While this can provide some consistency during the work period, it does not guarantee long-term continuity like permanent shift assignments. It is primarily a work-life balance tool rather than a specific strategy for maximizing patient care continuity.
Correct Answer is A
Explanation
An internal disaster in a healthcare facility requires the immediate activation of the Hospital Incident Command System (HICS). When critical infrastructure, such as power or emergency generators, fails, the primary objective is to maintain environmental stability and prevent chaos. The charge nurse must ensure that all personnel and patients are accounted for and that movement throughout the facility is restricted to prevent injuries during periods of low visibility or equipment failure.
Rationale:
A. Telling clients to stay in their rooms is the first and most vital instruction. During a total power failure, hallways may be dark, and electronic security systems may be compromised. Keeping clients in their rooms ensures their physical safety, prevents falls, and allows the nursing staff to perform an accurate headcount and assessment of immediate needs within a controlled environment.
B. Offering to assist in the intensive care unit (ICU) is a well-intentioned but disorganized response. While ventilator-dependent clients are at the highest risk during power failures, the reallocation of staff must be coordinated through the central command center. UAPs should not leave their assigned units until the charge nurse has established that their current clients are stable and supervised.
C. Shutting all doors "in case a fire erupts" is a specific protocol for a Fire Emergency (Code Red), not necessarily a general power failure. While keeping doors closed can be part of a safety check, the immediate priority during a generator malfunction is client accountability and communication. Fire protocols should only be prioritized if there is an actual threat of smoke or flames.
D. Going to the emergency department (ED) to complete tasks is inappropriate during an internal disaster. The ED will likely be managing its own surge of critical issues. Staff must remain on their assigned units to ensure the safety of the 350 beds already occupied. Straying from one's post without direct orders from the Incident Commander disrupts the organized disaster response plan.
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