Question

A client at 28-weeks’ gestation whose hemoglobin level is 10.7 g/dL (107 g/L) and hematocrit is 32% (0.32 volume fraction), tells the nurse that she eats plenty of green vegetables. When the client asks the nurse how the low-level value might affect her pregnancy, which information should the nurse provide?

Reference range:

Hemoglobin [12 to 16 g/dl (120 to 160 g/L): pregnant greater than 11 g/dl (110 g/L)] Hematocrit [37% to 47% (0.37 to 0.47 volume fraction): pregnant greater than 33% (0.33 volume fraction)]

Answer 1

Correct Answers:

Plasma volume increases, making the blood count appear low.

Rationale :

🟦 Placing a nightlight improves visibility during nighttime ambulation, which significantly reduces the risk of falls in older adults.

🟦 Many falls occur in low-light conditions when clients get up at night to use the bathroom or move around the home.

🟦 Adequate lighting supports environmental safety by helping the client identify obstacles and changes in floor level.

🟦 This intervention is simple, effective, and strongly recommended for fall prevention in the home.

🧩 Other options

🟦 Setting water heater to 130°F — Too hot; increases burn risk (recommended ≤120°F).

🟦 Wearing socks at night — Increases slipping risk; non-skid footwear is safer.

🟦 Covering extension cord with a rug — Creates a tripping and fire hazard, especially with oxygen equipment.

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Answer 2

Correct Answers:

Review the fetal heart rate pattern.

Rationale :

🟦 In active labor, fetal well-being is the priority, especially before allowing ambulation or a position change such as walking to the bathroom.

🟦 Reviewing the fetal heart rate (FHR) pattern ensures the fetus is tolerating labor and that no acute compromise (e.g., decelerations) is present.

🟦 Changes in maternal position or activity can affect uteroplacental perfusion and fetal oxygenation; therefore, fetal status must be verified first.

🟦 Confirming a reassuring FHR supports safe decision-making and aligns with maternal–fetal safety principles.

🧩 Other options

🟦 Determine cervical dilation — Important, but not the immediate priority before ambulation.

🟦 Check vaginal fluid pH — Indicated if membrane rupture is suspected, which is not stated.

🟦 Palpate the bladder — Useful later; does not supersede fetal assessment.

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Answer 3

Correct Answers

Blank 1 Correct Option: Polydipsia
Blank 2 Correct Option: Warm, Flushed Skin

Rationale :

🟦 Polydipsia):

🟦 Polydipsia (excessive thirst) is a classic sign of hyperglycemia, which is particularly concerning in this client with a history of poorly controlled gestational diabetes requiring insulin.

🟦 Although the current blood glucose is 140 mg/dL, postpartum hormonal shifts can cause rapid glucose fluctuations, increasing the risk of hyperglycemia.

🟦 Ongoing thirst may indicate inadequate glycemic control or developing metabolic imbalance.

🟦 This finding warrants continued blood glucose monitoring and possible adjustment of insulin therapy.

🟦 🌡️ Warm, Flushed Skin):

🟦 Warm, flushed skin in the immediate postpartum period may be an early indicator of infection or developing postpartum complications, especially with a history of prolonged labor and ruptured membranes for 12 hours.

🟦 Although the temperature is only mildly elevated, postpartum clients—particularly those with diabetes—are at increased risk for infection due to impaired immune response.

🟦 Early identification allows prompt evaluation for endometritis or systemic infection.

🟦 Close monitoring of temperature trends and additional symptoms is essential for timely intervention.

🧩 Why the other options are NOT priority concerns (brief):

🟡 Urine output — 400 mL of clear, yellow urine indicates adequate renal perfusion and hydration.

🟡 Moderate lochia — Expected finding after vaginal delivery.

🟡 Blood loss — Estimated blood loss of 300 mL is within normal limits for vaginal birth.

🟡 Weight loss — Not present or documented as a concern.

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Answer 4

Correct Answers

Frequent urination [ Hyperglycemia ]
Hunger [ Hypoglycemia ]
Fatigue [ Hyperglycemia ]
Sweating [ Hypoglycemia ]
Headache [ Hypoglycemia ]
Abdominal pain [ Hyperglycemia ]
Dry mouth [ Hyperglycemia ]

Rationale :

🟦 Frequent Urination → Hyperglycemia

🟦 Hyperglycemia causes osmotic diuresis as excess glucose is excreted by the kidneys, pulling water with it.

🟦 This leads to increased urine output and fluid loss.

🟦 In postpartum clients with a history of poor glycemic control, this finding requires follow-up.

🟦 It often occurs alongside polydipsia and dehydration.

🟢 Hunger → Hypoglycemia

🟢 Hunger is an early adrenergic response to low blood glucose levels.

🟢 The body signals the need for glucose to restore energy supply to the brain.

🟢 Insulin use increases the risk of hypoglycemia, especially postpartum when insulin needs can drop rapidly.

🟢 This symptom aligns with the client’s report of being “very hungry.”

🟣 Fatigue → Hyperglycemia

🟣 Hyperglycemia leads to cellular glucose deprivation despite high serum glucose levels.

🟣 Cells are unable to effectively use glucose for energy, resulting in fatigue and weakness.

🟣 Persistent fatigue is common when blood glucose remains elevated.

🟣 This is especially concerning in a client with recent insulin therapy adjustments.

🟥 Sweating → Hypoglycemia

🟥 Sweating is a classic sympathetic nervous system response to hypoglycemia.

🟥 Low blood glucose triggers catecholamine release, causing diaphoresis.

🟥 This is an early warning sign that requires prompt intervention.

🟥 It often occurs with tremors, anxiety, and palpitations.

🟠 Headache → Hypoglycemia

🟠 The brain depends almost exclusively on glucose for energy.

🟠 Hypoglycemia leads to neuroglycopenic symptoms, including headache.

🟠 Headache may occur before more severe symptoms such as confusion or loss of consciousness.

🟠 This finding warrants immediate blood glucose evaluation.

🟤 Abdominal Pain → Hyperglycemia

🟤 Hyperglycemia, especially when severe or prolonged, can cause gastrointestinal discomfort.

🟤 It may be associated with slowed gastric emptying and metabolic imbalance.

🟤 Abdominal pain is more consistent with elevated glucose than low glucose states.

🟤 This symptom should prompt monitoring for worsening hyperglycemia.

🟨 Dry Mouth → Hyperglycemia

🟨 Dry mouth results from dehydration caused by osmotic diuresis in hyperglycemia.

🟨 Fluid loss through frequent urination reduces salivary secretion.

🟨 This finding aligns with the client’s report of being extremely thirsty.

🟨 It reflects inadequate intracellular hydration due to elevated glucose levels.

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Answer 5

Correct Answers

Notify the healthcare provider [ Indicated ]
Encourage the client to breastfeed [ Not Indicated ]
Administer 60 units glargine insulin [ Not Indicated ]
Provide the client with milk to drink [ Indicated ]
Administer 8 units regular insulin [ Not Indicated ]

Rationale :

🟦 Notify the healthcare provider — Indicated

🟦 The client is showing mixed but concerning glucose-related symptoms (hunger, sweating, headache, fatigue) in the immediate postpartum period.

🟦 Insulin requirements often drop sharply after delivery, increasing the risk for hypoglycemia.

🟦 The provider must be notified to reassess insulin dosing and glucose monitoring orders.

🟦 Early communication helps prevent severe glycemic events.

🟩 Encourage the client to breastfeed — Not Indicated

🟩 The client is bottle-feeding, and no desire to breastfeed has been expressed.

🟩 Breastfeeding is a client choice and should not be encouraged if it does not align with the client’s plan.

🟩 This intervention is not relevant to the current priority of glycemic management.

🟥 Administer 60 units glargine insulin — Not Indicated

🟥 This is a large dose of long-acting insulin, which could cause severe hypoglycemia postpartum.

🟥 The client is already showing possible hypoglycemic symptoms.

🟥 Insulin doses must be re-evaluated after delivery, not automatically continued.

🟥 Administering this dose would be unsafe at this time.

🟠 Provide the client with milk to drink — Indicated

🟠 The client reports hunger, weakness, sweating, and headache, which are classic signs of hypoglycemia.

🟠 Milk provides both carbohydrates and protein, making it appropriate for treating mild hypoglycemia.

🟠 This is a safe, immediate nursing intervention while awaiting glucose confirmation or provider guidance.

🟠 Oral intake is appropriate because the client is alert and oriented.

🟣 Administer 8 units regular insulin — Not Indicated

🟣 Regular insulin would lower blood glucose further, worsening suspected hypoglycemia.

🟣 There is no current elevated blood glucose value to justify insulin administration.

🟣 Insulin should never be given based on symptoms alone without confirmed hyperglycemia.

🟣 This intervention could place the client at risk for acute hypoglycemic crisis.

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Answer 6

Correct Answers:

Monitor for temperatures greater than 100.4" F (38° C).
Check blood sugar before breastfeeding.
Schedule a glucose tolerate test in 6 weeks.
Wear a medical-alert bracelet.

Rationale :

🟦 💎 Wear a medical-alert bracelet —

💎 Wearing a medical-alert bracelet ensures rapid identification of the client’s diabetes history in emergency situations.

💎 This is especially important postpartum, when glucose levels can fluctuate and hypoglycemia may occur unexpectedly.

💎 Emergency responders rely on this information to deliver safe, appropriate treatment.

💎 This demonstrates the client understands long-term self-safety and risk prevention.

🟦 💎 Monitor for temperatures greater than 100.4°F (38°C) —

💎 Postpartum clients are at increased risk for infection, particularly with a history of prolonged labor and diabetes.

💎 Monitoring for fever allows early detection of endometritis, wound infection, or systemic infection.

💎 Prompt reporting of elevated temperature supports timely intervention and reduces complications.

💎 This reflects understanding of postpartum warning signs.

🟦 💎 Check blood sugar before breastfeeding —

💎 Breastfeeding can lower maternal blood glucose levels, increasing the risk for hypoglycemia.

💎 Checking blood sugar beforehand helps the client prevent symptomatic hypoglycemia.

💎 This practice supports safe glucose management during lactation.

💎 The statement shows understanding of how feeding affects glucose control.

🟦 💎 Schedule a glucose tolerance test in 6 weeks —

💎 Clients with gestational diabetes require a postpartum glucose tolerance test to assess for persistent diabetes.

💎 The 6-week timeframe aligns with clinical guidelines once pregnancy-related insulin resistance resolves.

💎 Early testing allows timely diagnosis and long-term management if diabetes persists.

💎 This demonstrates understanding of follow-up care and prevention.

❌ Statements that do NOT indicate understanding (brief):

Insulin requirements increase with lactation — Insulin needs usually decrease postpartum.

Eat 15 g carbohydrates if glucose <150 mg/dL — Treatment threshold is <70 mg/dL, not 150.

Avoid low-dose contraceptives postpartum — Low-dose options may be appropriate depending on individual risk.

Eat 500 additional calories daily — Applies to breastfeeding clients; this client is bottle-feeding.

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Answer 7

Correct Answers:

Provide positive pressure ventilation.

Rationale :

🟢 The newborn has a heart rate of 100 beats/min, which is adequate but is not breathing spontaneously.

🟢 According to neonatal resuscitation guidelines, apnea or ineffective respirations require immediate positive pressure ventilation (PPV).

🟢 Initial steps such as warming, drying, suctioning, and tactile stimulation have already been performed without success.

🟢 PPV helps establish effective lung expansion and oxygenation, which is the priority at this point.

🟢 Early ventilation prevents hypoxia, acidosis, and bradycardia in the newborn.

❌ Start IV infusion in a scalp vein

IV access is not the immediate priority in an apneic newborn. Establishing ventilation comes first.

❌ Assist neonatologist with intubation

Intubation is reserved if PPV is ineffective. Less invasive ventilation is attempted first.

❌ Give blow-by oxygen via cannula

Blow-by oxygen does not correct apnea. The infant requires assisted ventilation, not supplemental oxygen alone.

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Answer 8

Correct Answers:

Take an oral maternal temperature.

Rationale :

🔴 A sustained fetal heart rate of 170–180 beats/min indicates fetal tachycardia.

🔴 One of the most common causes is maternal infection, especially after spontaneous rupture of membranes (SROM).

🔴 Checking the maternal temperature helps identify chorioamnionitis or maternal fever.

🔴 Maternal hyperthermia directly increases fetal metabolic rate and heart rate.

🔴 Early identification allows prompt intervention to reduce fetal compromise.

❌ Obtain a blood specimen for hemoglobin

Hemoglobin levels do not explain acute fetal tachycardia. Infection must be ruled out first.

❌ Send amniotic fluid for analysis

This is not a first-line bedside intervention. Maternal assessment takes priority.

❌ Straight catheterize the client

Bladder distention may affect labor progress, not fetal heart rate.

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Answer 9

Correct Answers:

Assist the mother to elicit a rooting reflex in the infant.

Rationale :

🟣 The rooting reflex helps the newborn locate the nipple and begin feeding.

🟣 Stimulating this reflex supports early latch and effective breastfeeding.

🟣 Early breastfeeding promotes uterine contraction and bonding.

🟣 Assisting with positioning and reflexes increases maternal confidence.

🟣 This intervention directly supports the mother’s stated breastfeeding goal.

❌ Permit privacy for the mother and infant to bond

Bonding is important but does not actively assist with breastfeeding initiation.

❌ Evaluate the infant's sucking reflex then give the infant to the mother

Assessment alone does not help initiate feeding. Hands-on assistance is needed.

❌ Place a small amount of glucose water on the breast

Glucose water interferes with breastfeeding and is not recommended.

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Answer 10

Correct Answers:

Rubella vaccination.

Rationale :

🟢 The client is rubella non-immune, placing her at risk for congenital rubella syndrome in future pregnancies.

🟢 Rubella vaccination is indicated in the postpartum period because it is a live attenuated vaccine and cannot be given during pregnancy.

🟢 Administering the vaccine now allows the mother to develop protective antibodies before a subsequent pregnancy.

🟢 The client’s hemoglobin and hematocrit are within acceptable postpartum limits, eliminating the need for transfusion.

🟢 Providing the vaccine before discharge ensures long-term maternal and fetal protection.

❌ Hepatitis B immunoglobulin

This is indicated only if the mother is hepatitis B surface antigen positive. The client’s results are negative.

❌ Blood transfusion

The hemoglobin and hematocrit values are within normal postpartum ranges. There is no evidence of hemorrhage or anemia.

❌ Penicillin G potassium

GBS prophylaxis is administered during labor, not postpartum. Antibiotics are not routinely given after delivery for GBS positivity alone.

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Plan of Care Recommendation	Indicated	Not Indicated
Notify the healthcare provider
Encourage the client to breastfeed
Administer 60 units glargine insulin
Provide the client with milk to drink
Administer 8 units regular insulin

QLexNursing

2 :
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

3 :
A nurse was assessing a patient

Correct Answers

4 :
Patient data

Correct Answers

🟦 Frequent Urination → Hyperglycemia

🟢 Hunger → Hypoglycemia

🟣 Fatigue → Hyperglycemia

🟥 Sweating → Hypoglycemia

🟠 Headache → Hypoglycemia

🟤 Abdominal Pain → Hyperglycemia

🟨 Dry Mouth → Hyperglycemia

5 :
Patient data

Correct Answers

🟦 Notify the healthcare provider — Indicated

🟩 Encourage the client to breastfeed — Not Indicated

🟥 Administer 60 units glargine insulin — Not Indicated

🟠 Provide the client with milk to drink — Indicated

🟣 Administer 8 units regular insulin — Not Indicated

6 :
The nurse starts discharge teaching. Which findings indicate the client understands the discharge teaching? Select all that apply.

9 :
While on the delivery table, a primipara tells the nurse that she wishes to breastfeed her infant. To assist the new mother with her goal, which intervention is best for the nurse to implement?

Client Findings	Hypoglycemia	Hyperglycemia
Frequent urination
Hunger
Fatigue
Sweating
Headache
Abdominal pain
Dry mouth

QLexNursing

2 : The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

3 : A nurse was assessing a patient

Correct Answers

4 : Patient data

Correct Answers

🟦 Frequent Urination → Hyperglycemia

🟢 Hunger → Hypoglycemia

🟣 Fatigue → Hyperglycemia

🟥 Sweating → Hypoglycemia

🟠 Headache → Hypoglycemia

🟤 Abdominal Pain → Hyperglycemia

🟨 Dry Mouth → Hyperglycemia

5 : Patient data

Correct Answers

🟦 Notify the healthcare provider — Indicated

🟩 Encourage the client to breastfeed — Not Indicated

🟥 Administer 60 units glargine insulin — Not Indicated

🟠 Provide the client with milk to drink — Indicated

🟣 Administer 8 units regular insulin — Not Indicated

6 : The nurse starts discharge teaching. Which findings indicate the client understands the discharge teaching? Select all that apply.

9 : While on the delivery table, a primipara tells the nurse that she wishes to breastfeed her infant. To assist the new mother with her goal, which intervention is best for the nurse to implement?

2 :
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

3 :
A nurse was assessing a patient

4 :
Patient data

5 :
Patient data

6 :
The nurse starts discharge teaching. Which findings indicate the client understands the discharge teaching? Select all that apply.

9 :
While on the delivery table, a primipara tells the nurse that she wishes to breastfeed her infant. To assist the new mother with her goal, which intervention is best for the nurse to implement?