A prenatal client is experiencing calf pain when she walks. Which action is appropriate for the nurse to implement?
Instruct the client to limit walking episodes.
Tell the client that this is normal during pregnancy.
Gather further assessment data
Instruct the client to elevate the legs consistently throughout the day.
The Correct Answer is C
Rationale:
A. Limiting walking episodes may reduce discomfort but does not address the underlying issue or potential complications.
B. While leg cramps can be common during pregnancy, calf pain could also indicate a more serious condition, such as deep vein thrombosis (DVT), and should not be dismissed as normal without further investigation.
C. Gathering further assessment data is crucial to determine the cause of the calf pain, as it may indicate DVT, a potentially life-threatening condition. The nurse should assess for other symptoms like swelling, redness, or warmth in the leg.
D. Instructing the client to elevate the legs may be appropriate for general discomfort, but without proper assessment, it may not be the correct intervention if DVT is present.
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Correct Answer is C
Explanation
Rationale:
A. Assisting the client to the bathroom might be helpful, but it is not the first action the nurse should take since the client hasn't voided for an extended period.
B. Increasing fluids may be beneficial but does not address the immediate concern of whether there is a problem with urinary retention.
C. Performing a bladder scan is the first action to determine if there is urine retention in the bladder. This information is crucial before deciding on further interventions, such as catheterization.
D. Inserting a straight catheter may be necessary if significant urinary retention is confirmed, but it should not be the first action without knowing the bladder's status.
Correct Answer is A
Explanation
Rationale:
A. Injecting insulin into the abdominal area is appropriate as it is one of the preferred sites for insulin administration due to its consistent absorption.
B. Blood sugar readings should be taken before meals, not after, to determine the need for insulin and to manage blood glucose levels effectively.
C. Insulin does not allow for unrestricted consumption of high-sugar foods like ice cream; instead, a balanced diet is important to maintain stable blood glucose levels.
D. While weight reduction can help manage diabetes, it does not inherently cause hypoglycemia unless the client is taking insulin or other medications that lower blood glucose.