A nurse is reinforcing teaching to a client who is pregnant regarding a 1-hr glucose tolerance test (GTT). Which of the following statements by the client indicates an understanding of the test?
"This test is to check if my baby has diabetes.”
"If the result is higher than normal, I will need to be on insulin the rest of my life.”
"If I forget and eat before the test, then I won't be able to have the test done.”
"If the results are high, then I need another test to see if I have gestational diabetes.”
The Correct Answer is D
Choice A reason:
The client stating, "This test is to check if my baby has diabetes,” indicates a misunderstanding of the purpose of the 1-hr glucose tolerance test (GTT). The test is performed to screen for gestational diabetes in the mother, not to check the baby's diabetes status. Rationale: Gestational diabetes is a condition where high blood sugar levels develop during pregnancy, and it can affect both the mother and the baby's health.
Choice B reason:
The client mentioning, "If the result is higher than normal, I will need to be on insulin the rest of my life,” demonstrates a misconception about the implications of the 1-hr GTT. The 1-hr GTT is a preliminary screening test, and if the results are higher than normal, it indicates the need for further evaluation, but it does not immediately mean a lifetime dependence on insulin. Rationale: Insulin therapy may be required for managing gestational diabetes in some cases, but not necessarily for the rest of the mother's life.
Choice C reason:
The client saying, "If I forget and eat before the test, then I won't be able to have the test done,” indicates a misunderstanding of the test procedure. The 1-hr GTT requires fasting before the test, typically for 8 to 14 hours, to get accurate results. However, if the client mistakenly eats before the test, it doesn't mean they cannot have the test done at all; they may need to reschedule it after an appropriate fasting period. Rationale: Fasting is crucial for accurate glucose level measurement during the test.
Choice D reason:
The client stating, "If the results are high, then I need another test to see if I have gestational diabetes,” demonstrates a correct understanding of the 1-hr GTT. If the initial screening test shows elevated glucose levels, further testing, such as the 3-hour glucose tolerance test (GTT), is required to confirm the diagnosis of gestational diabetes. Rationale: The 3-hour GTT is a more comprehensive diagnostic test used to confirm or rule out gestational diabetes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Obtaining vital signs is essential in assessing the child's overall condition, but it is not the first action the nurse should take in this situation. The priority is to address the immediate concern of difficulty breathing.
Choice B reason:
Stopping the IV infusion is the most critical action the nurse should take first. Difficulty breathing can be a sign of a severe allergic reaction, and if it is related to the IV cefuroxime, stopping the infusion will prevent further administration of the medication and possibly worsening the reaction.
Choice C reason:
Administering epinephrine IM is not the first-line action in this scenario. Epinephrine is used in severe anaphylactic reactions, but it should not be given without a proper evaluation of the situation and a clear indication for its use.
Choice D reason:
Monitoring intake and output is an important nursing intervention, but it is not the priority when the child is experiencing difficulty breathing. Addressing the respiratory distress should be the initial focus to ensure the child's safety and well-being.
Correct Answer is C
Explanation
Choice A reason:
The nurse should not offer the child sips of clear liquids during a seizure. During a tonic-clonic seizure, the child's swallowing reflex may be impaired, and giving liquids could lead to aspiration or choking, causing further complications.
Choice B reason:
The nurse should not restrain the child during a seizure using both arms or any other means. Restraint can potentially lead to injury for both the child and the person attempting to restrain them. It is crucial to allow the child to move freely during the seizure to prevent harm.
Choice C reason:
Placing the child's head on a pillow is the correct choice. This positioning helps to protect the child's head from injury during the seizure. The pillow provides a cushioning effect, minimizing the risk of head trauma.
Choice D reason:
The nurse should not instruct the parent to give rectal diazepam to the child at the onset of the seizure unless specifically prescribed by the child's healthcare provider. Diazepam is a medication used to manage seizures, but its administration route and timing should be determined by the child's healthcare provider. Inappropriate use of medication can be dangerous and ineffective.
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