QUESTION: "Which of the following would the nurse expect to include in the plan of care for a client with diabetes who is in labor?"
CHOICES
( X ) a.) Measuring urine output every 4 hours.
( X ) b.) Administering insulin subcutaneously every 4 hours.
( X ) c.) Checking deep tendon reflexes every 2 hours.
( O ) d.) Monitoring blood glucose levels every hour.
RATIONALE: Because metabolic changes occur during labor and delivery, close monitoring of the diabetic client's blood glucose level-every hour, during labor-is necessary. There is no indication that the client's urine output needs to be measured every 4 hours. The need for insulin administration is determined by the client's blood glucose levels. If needed, insulin is usually given intravenously. Checking deep tendon reflexes would be necessary if the client had pregnancy-induced hypertension. However, because pregnant clients with diabetes are at higher risk for developing pregnancy-induced hypertension, any evidence of protein in the urine should be reported. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
