A nurse is reinforcing teaching with a client who has gestational diabetes mellitus.
Which of the following statements by the client indicates an understanding of the teaching?
“My baby will be monitored for hypoglycemia after birth.”
“I will check my blood glucose once every 8 hours.”
“My baby is at risk for being underweight at birth.”
“I should ensure that only 5 percent of my daily calories come from protein sources.”
The Correct Answer is A
This statement indicates an understanding of the teaching because babies born to mothers with gestational diabetes mellitus (GDM) are at risk for low blood sugar (hypoglycemia) after birth due to high insulin levels.
Choice B is wrong because a client who has GDM should check their blood glucose more frequently than once every 8 hours. The American Diabetes Association recommends checking blood glucose levels before meals and one hour after the start of each meal.
Choice C is wrong because a baby born to a mother with GDM is at risk for being overweight (macrosomia) at birth, not underweight. This can lead to complications such as shoulder dystocia, birth trauma, and cesarean delivery.
Choice D is wrong because a client who has GDM should ensure that about 15 to 20 percent of their daily calories come from protein sources, not 5 percent. Protein helps regulate blood glucose levels and supports fetal growth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Place the newborn on a flat surface and clap hands loudly.
This action will elicit the Moro reflex, also known as the startle reflex, which is a normal, involuntary reaction that newborns and infants have when they’re startled. In response to the sound, the baby will throw back his or her head, extend out his or her arms and legs, cry, then pull the arms and legs back in.
Choice A is wrong because placing the newborn on their abdomen and observing the movement of their extremities will not trigger the Moro reflex.
This position may elicit other reflexes such as the crawling reflex or the tonic neck reflex.
Choice B is wrong because stroking the newborn’s cheek toward their mouth will not trigger the Moro reflex. This action will elicit the rooting reflex, which helps the baby find the breast or bottle to start feeding.
Choice C is wrong because stroking upward on the lateral aspect of the newborn’s foot will not trigger the Moro reflex. This action will elicit the Babinski reflex, which causes the big toe to extend upward and the other toes to fan out.
Correct Answer is A
Explanation
Offer the client fluids high in fiber and protein every hour. This is because clients who have bipolar disorder and are experiencing mania are at risk of dehydration, malnutrition, and weight loss due to increased activity, poor intake, and impaired judgment. Fluids high in fiber and protein can help prevent constipation and promote satiety.
Choice B is wrong because monitoring the client’s vital signs twice per day is not enough for a client who has mania. The nurse should monitor the client’s vital signs more frequently, at least every 4 hours, to assess for signs of dehydration, infection, or cardiac complications.
Choice C is wrong because encouraging the client to participate in group therapy activities each day can increase the client’s stimulation and agitation. The nurse should provide a calming environment with fewer stimuli and solitary activities for a client who has mania.
Choice D is wrong because weighing the client three times per week is not sufficient for a client who has mania. The nurse should weigh the client daily to monitor for weight loss and fluid imbalance.
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