A nurse is caring for a 24-year-old female client in the primary health care provider's office.
Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
Fundal height 27 cm at 21 weeks gestation
Fetal heart tones 145/min
Oral Glucose Tolerance Test: 1-hour result 220 mg/dL
Oral Glucose Tolerance Test: 3-hour result 142 mg/dL
Blood pressure 140/88 mm Hg
Denies headaches, visual disturbances, and epigastric pain
Correct Answer : A,C,D,E
Choice A rationale: A fundal height of 27 cm at 21 weeks gestation exceeds the expected range. Normally, fundal height in centimeters should approximate gestational age between 20 and 36 weeks, with a ±2 cm margin. At 21 weeks, a fundal height of 19–23 cm is acceptable. A measurement of 27 cm suggests possible fetal macrosomia, polyhydramnios, or gestational diabetes, especially in a client with elevated glucose levels and obesity. This warrants follow-up.
Choice B rationale: Fetal heart tones of 145/min fall within the normal range of 110 to 160 beats per minute. This rate reflects appropriate fetal autonomic regulation and oxygenation. Variability in fetal heart rate is expected and indicates a healthy intrauterine environment. No arrhythmia or bradycardia is present. Therefore, this finding does not require follow-up and supports normal fetal well-being at this gestational age.
Choice C rationale: A 1-hour glucose level of 220 mg/dL following a 100-g oral glucose load exceeds the threshold of less than 180 mg/dL. This result indicates impaired glucose tolerance and supports the diagnosis of gestational diabetes mellitus (GDM). GDM increases risks for fetal macrosomia, shoulder dystocia, and neonatal hypoglycemia. Follow-up is required to initiate dietary management, glucose monitoring, and possibly pharmacologic therapy to prevent maternal and fetal complications.
Choice D rationale: A 3-hour glucose level of 142 mg/dL exceeds the normal range of 70 to 115 mg/dL. This result confirms abnormal glucose metabolism and supports the diagnosis of gestational diabetes. The 3-hour value reflects delayed glucose clearance and persistent hyperglycemia. This finding, in conjunction with other elevated values, meets criteria for GDM and necessitates follow-up for glycemic control, nutritional counseling, and fetal surveillance to mitigate adverse outcomes.
Choice E rationale: A blood pressure of 140/88 mm Hg meets the threshold for gestational hypertension, defined as systolic ≥140 mm Hg or diastolic ≥90 mm Hg after 20 weeks gestation. Although the client denies symptoms of preeclampsia, such as headache or visual changes, her history of chronic hypertension and obesity increases risk. Continued monitoring and possible adjustment of antihypertensive therapy are warranted to prevent progression to preeclampsia or eclampsia.
Choice F rationale: Denial of headaches, visual disturbances, and epigastric pain suggests absence of preeclampsia symptoms. These symptoms reflect end-organ involvement and vasospasm in severe hypertensive disorders. Their absence supports stable maternal status. However, clinical vigilance remains important due to the client’s elevated blood pressure and risk factors. At this time, no follow-up is required solely based on symptom denial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The American Academy of Pediatrics recommends that term newborns should be fed on demand or at least every 3 to 4 hours, which provides sufficient caloric intake for growth and prevents hypoglycemia. Formula is digested more slowly than breast milk, so offering a bottle every 3 to 3 1/2 hours is generally appropriate to meet the infant's nutritional needs and satisfy hunger cues. Regular feeding supports adequate weight gain, which is a critical developmental milestone in the neonatal period.
Choice B rationale
For the first few weeks, the nurse should instruct the guardian to wake a sleepy newborn if more than 4 hours have passed since the last feeding to prevent excessive weight loss and hypoglycemia, as their small glycogen stores are rapidly depleted. However, after the initial period and once the infant is feeding well and gaining weight appropriately (usually about 2 weeks old), night waking is typically not necessary.
Choice C rationale
Diluting ready-to-feed formula by adding filtered water is contraindicated because it reduces the caloric and nutrient density below required levels for the newborn's growth. The proper ratio of formula powder or concentrate to water is crucial for providing essential electrolytes, protein, and carbohydrates. Dilution can lead to water intoxication or hyponatremia and cause serious neurological complications due to electrolyte imbalance.
Choice D rationale
Prepared infant formula should be used or discarded within 24 hours if stored in the refrigerator, not 72 hours. Bacteria can rapidly proliferate in prepared formula, even under refrigeration, increasing the risk of gastrointestinal infection for the newborn. Formula ready-to-feed containers, once opened, should also be used within 24 to 48 hours or discarded to maintain optimal safety.
Correct Answer is B
Explanation
Choice A rationale
A BP of 105/62 mm Hg is within the expected normal range for a postpartum adolescent client. A typical normotensive range is 90-140 mm Hg systolic and 60-90 mm Hg diastolic. Opioids like morphine can cause mild hypotension, but this reading doesn't indicate an immediate, life-threatening crisis.
Choice B rationale
A respiratory rate of 11/min is the priority because it signifies respiratory depression, a life-threatening, dose-related adverse effect of opioid analgesics like morphine. The normal respiratory rate for an adolescent is 12-20 breaths/min. Rates ≤ 12/min require immediate intervention, including potential administration of an opioid antagonist like naloxone.
Choice C rationale
Urinary retention is a common side effect of opioid administration due to increased bladder sphincter tone and reduced detrusor muscle contractility. While uncomfortable and potentially leading to urinary tract infection or bladder damage, it is less acute and life-threatening than respiratory depression.
Choice D rationale
Blurred vision can be an uncommon side effect of morphine, possibly due to miosis (pupil constriction) or minor changes in intraocular pressure. This finding requires further assessment but is a non-life-threatening adverse effect and does not pose the immediate threat of respiratory depression.
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