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 ["A"]
Explanation
Choice A reason: The correct answer is choice A. The nurse should expect the presence of the Moro reflex in a 6-month-old infant. The Moro reflex is a normal primitive reflex seen in infants up to about 6 months of age. When the infant experiences a sudden loss of support or a loud noise, they react by extending their arms and legs and then pulling them back in, as if trying to grasp onto something. This reflex is an important indicator of the baby's neurological development.
Choice B reason:
The birth weight doubling by 6 months of age is a typical growth milestone for infants. However, this statement is not correct in the context of the question, as it is not something the nurse should "expect” during a well-child visit. Instead, it is a general developmental milestone that healthcare providers monitor over time.
Choice C reason:
The correct answer is choice C. The nurse should expect the posterior fontanel to be closed in a 6-month-old infant. Fontanels are soft spots on a baby's skull that allow for brain growth during early development. The posterior fontanel, located at the back of the head, is typically closed by 6 months of age.
Choice D reason:
The correct answer is choice D. At 6 months of age, many infants can sit unsupported. However, not all infants achieve this milestone at the exact same age. Some may achieve it a bit earlier, while others might take a little more time. It is essential for the nurse to assess the infant's developmental progress and provide appropriate guidance to the parents.
Choice E:
The correct answer is choice E. By 6 months of age, some infants may be able to move from their back to their front. This is usually accomplished through rolling over. However, like other developmental milestones, the age at which infants achieve this can vary. Therefore, while the nurse may expect this ability in some infants, it is not something that all 6-month- old infants will have mastered at the time of the well-child visit.
Correct Answer is C
Explanation
"I will reinforce the patch edges with clear tape if they don't lie flat.".
Choice A reason:
Placing a heat pack on the patch to improve adhesion is not recommended. Heat can potentially increase the absorption of the medication and lead to adverse effects. Applying additional heat to the patch can be dangerous and may cause an overdose or other complications.
Choice B reason:
Placing the patch on the back side of the child's arm is not the correct application site for a methylphenidate transdermal patch. The appropriate site for application is typically the hip or the top of the buttocks. The back of the arm may not provide proper absorption and can result in suboptimal medication delivery.
Choice C reason:
This statement indicates an understanding of the teaching. Reinforcing the patch edges with clear tape if they don't lie flat is a recommended step to ensure proper adhesion of the patch. If the edges of the patch lift or don't stick properly, using clear tape can help keep the patch securely in place, ensuring continuous and consistent drug delivery.
Choice D reason:
Leaving the patch in place for no more than 9 hours is incorrect. The duration of wear for a methylphenidate transdermal patch varies depending on the specific brand and formulation. Typically, these patches are designed for 9 to 12 hours of wear, and leaving them on for a shorter duration may result in inadequate symptom control.
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