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 ["C","D"]
Explanation
Choice A rationale
. Decreased urination, or oliguria, is typically associated with fluid volume deficit or impaired renal perfusion, not directly with uncomplicated hyperglycemia. In fact, hyperglycemia causes an osmotic diuresis because the excess glucose filtered by the glomeruli exceeds the renal tubules' reabsorption capacity. This results in the excretion of glucose, which draws water with it, leading to polyuria (increased urination), the opposite of the expected manifestation. Normal blood glucose is 70 to 100 mg/dL.
Choice B rationale
. Shallow respirations are not a characteristic sign of hyperglycemia in a client who is pregnant, unless the condition has progressed to severe diabetic ketoacidosis (DKA). DKA causes a metabolic acidosis, which triggers Kussmaul respirations—deep and labored breathing—as a compensatory mechanism to increase CO_2 elimination and raise the blood pH. Shallow breathing would decrease ventilation.
Choice C rationale
. Increased hunger, or polyphagia, is a classic manifestation of hyperglycemia due to the body's inability to utilize glucose effectively as an energy source, despite high blood glucose levels. The cells signal a state of starvation because glucose cannot enter the cells without sufficient insulin, prompting the release of neuropeptides that stimulate appetite and increased caloric intake.
Choice D rationale
. Increased thirst, or polydipsia, is a direct physiological response to the osmotic diuresis caused by hyperglycemia. The high concentration of glucose in the blood increases the plasma osmolarity, which pulls water from the intracellular space into the vascular space, causing cellular dehydration. This triggers the osmoreceptors in the hypothalamus, stimulating the sensation of thirst to encourage fluid intake.
Correct Answer is D
Explanation
Choice A rationale
Calcium is essential for fetal bone and tooth development, as well as for maternal skeletal integrity, muscle function, and blood clotting. Although crucial, an increase in calcium intake (normal recommended intake is 1000 mg/day for most pregnant women) is primarily aimed at skeletal and cellular health, not specifically at the physiological increase in maternal blood volume, which necessitates increased erythrocyte production and plasma volume.
Choice B rationale
Vitamin E is an important fat-soluble antioxidant that protects cell membranes from oxidative damage and plays a role in red blood cell (RBC) integrity. While it is necessary for overall maternal and fetal health, its primary function is not directly linked to the significant expansion of maternal plasma and erythrocyte mass, which is the physiological basis for the approximately 30% to 50% increase in maternal blood volume during pregnancy.
Choice C rationale
Vitamin D is a fat-soluble vitamin critical for intestinal absorption of calcium and phosphorus, thereby maintaining optimal bone mineralization and immune function. Although supplementation is often necessary, especially in those with limited sun exposure (normal range 20-50 ng/mL), its primary role is in calcium homeostasis and immune function, not as a direct substrate for the substantial increase in maternal plasma volume and red blood cell mass during gestation.
Choice D rationale
Iron is a fundamental component of the heme group in hemoglobin, which is crucial for oxygen transport by red blood cells (RBCs). The approximately 45% increase in maternal blood volume during pregnancy requires a substantial increase in RBC production (erythropoiesis) to prevent dilutional anemia. Therefore, increased iron intake (normal recommended intake 27 mg/day) is vital for the necessary synthesis of hemoglobin to support this physiologic increase in maternal erythrocyte volume.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.