Part 2 of 3: “Action to Take”   DATE TIME NURSES’ NOTES…

Part 2 of 3: “Action to Take”   DATE TIME NURSES’ NOTES November 1, 2025 0820 Client Ms. Lewis is 21-year-old female with blood glucose of 864 mg/dL and serum potassium level of 3.9 mEq/L reports abdominal pain, headache, fatigue, frequent urination, excessive thirst, has rapid deep breathing and fruity sweet-smelling breath.  The nurse is reviewing the client’s assessment data to prepare the client’s plan of care. Identify what TWO actions the nurse should take FIRST.

A 37-week pregnant woman with ruptured membranes for 26 hour…

A 37-week pregnant woman with ruptured membranes for 26 hours and is Group Beta Streptococcus (GBS) positive. Highest maternal temp was 100.6 orally 2 hours ago. She undergoes a cesarean delivery for failure to progress. Fetal monitoring prior to birth shows a heart rate of 180 with minimal variability. At birth, the neonate exhibits tachypnea, pallor, hyperthermia, and Apgar scores of 6 and 7 at 1 and 5 minutes, respectively. Given the maternal and fetal history, critically analyze the potential multifactorial causes for the newborn’s presentation, considering the following possibilities: 

Part 2 of 3: “Action to Take”   DATE TIME NURSES’ NOTES…

Part 2 of 3: “Action to Take”   DATE TIME NURSES’ NOTES November 1, 2025 0820 Client Ms. Lewis is 21-year-old female with blood glucose of 864 mg/dL and serum potassium level of 3.9 mEq/L reports abdominal pain, headache, fatigue, frequent urination, excessive thirst, has rapid deep breathing and fruity sweet-smelling breath.  The nurse is reviewing the client’s assessment data to prepare the client’s plan of care. Identify what TWO actions the nurse should take FIRST.

A 37-week pregnant woman with ruptured membranes for 26 hour…

A 37-week pregnant woman with ruptured membranes for 26 hours and is Group Beta Streptococcus (GBS) positive. Highest maternal temp was 100.6 orally 2 hours ago. She undergoes a cesarean delivery for failure to progress. Fetal monitoring prior to birth shows a heart rate of 180 with minimal variability. At birth, the neonate exhibits tachypnea, pallor, hyperthermia, and Apgar scores of 6 and 7 at 1 and 5 minutes, respectively. Given the maternal and fetal history, critically analyze the potential multifactorial causes for the newborn’s presentation, considering the following possibilities: 

Part 2 of 3: “Action to Take”   DATE TIME NURSES’ NOTES…

Part 2 of 3: “Action to Take”   DATE TIME NURSES’ NOTES November 1, 2025 0820 Client Ms. Lewis is 21-year-old female with blood glucose of 864 mg/dL and serum potassium level of 3.9 mEq/L reports abdominal pain, headache, fatigue, frequent urination, excessive thirst, has rapid deep breathing and fruity sweet-smelling breath.  The nurse is reviewing the client’s assessment data to prepare the client’s plan of care. Identify what TWO actions the nurse should take FIRST.

A 37-week pregnant woman with ruptured membranes for 26 hour…

A 37-week pregnant woman with ruptured membranes for 26 hours and is Group Beta Streptococcus (GBS) positive. Highest maternal temp was 100.6 orally 2 hours ago. She undergoes a cesarean delivery for failure to progress. Fetal monitoring prior to birth shows a heart rate of 180 with minimal variability. At birth, the neonate exhibits tachypnea, pallor, hyperthermia, and Apgar scores of 6 and 7 at 1 and 5 minutes, respectively. Given the maternal and fetal history, critically analyze the potential multifactorial causes for the newborn’s presentation, considering the following possibilities: