A nurse is reinforcing teaching with a newly licensed nurse about incident reports.
The nurse should identify that which of the following situations requires the completion of an incident report?

Blood glucose 130 mg/dL.

This is because the normal range of blood glucose for pregnant women is 70 - 110 mg/dL .

A blood glucose level of 130 mg/dL indicates gestational diabetes, which can have adverse effects on the mother and the fetus.

The nurse should report this finding to the provider and initiate interventions such as dietary counseling, glucose monitoring, and insulin therapy if needed.

Choice A is wrong because WBC 7,000/mm³ is within the normal range for pregnant women, which is 4,500 to 10,000 cells/mcL .

A low WBC count would indicate an increased risk of infection, while a high WBC count would indicate inflammation or infection.

Choice B is wrong because hemoglobin 13 g/dL is within the normal range for pregnant women, which is 11 to 14 g/dL .

A low hemoglobin level would indicate anemia, while a high hemoglobin level would indicate dehydration or polycythemia.

Choice D is wrong because RBC 5.8 million/mm³ is within the normal range for pregnant women, which is 4.2 to 5.9 million/mm³ .

A low RBC count would indicate anemia or hemorrhage, while a high RBC count would indicate dehydration or polycythemia.

Administer analgesia. The child is likely experiencing pain and discomfort after the tonsillectomy, which can cause frequent swallowing. Analgesia can help relieve the pain and reduce the risk of bleeding.

Choice A is wrong because checking the back of the throat with a pen light can cause trauma and bleeding to the surgical site. The nurse should avoid using any instruments or objects in the mouth of the child after a tonsillectomy.

Choice B is wrong because obtaining the child’s vital signs in 15 min is not a priority action. The nurse should monitor the child’s vital signs more frequently, especially for signs of bleeding such as increased pulse and decreased blood pressure.

Choice D is wrong because offering the child a drink of water can cause irritation and bleeding to the throat. The nurse should avoid giving the child any fluids or foods by mouth until the gag reflex returns and the child is fully awake. The nurse should also avoid giving the child any fluids or foods that are acidic, carbonated, hot, or spicy, as they can cause pain and bleeding.