A nurse is reviewing the laboratory report of a client who is at 6 weeks of gestation. Which of the following laboratory results should the nurse report to the provider?
WBC count 10,000/mm3 (5.000 to 10,000/mm3
Fasting blood glucose 80 mg/dL (74 to 106 mg/dL)
Hematocrit 30% (37% to 47%)
RBC count 6 million/mm (4.2 to 6.1 million/mm)
The Correct Answer is C
Rationale:
A. WBC count 10,000/mm³ (5,000 to 10,000/mm³): This value is at the upper limit of normal. Mild elevations can occur during early pregnancy due to physiological changes and do not typically require immediate reporting unless accompanied by signs of infection.
B. Fasting blood glucose 80 mg/dL (74 to 106 mg/dL): This value falls within the normal fasting glucose range for adults and is not concerning during early pregnancy. No intervention or reporting is necessary for this result.
C. Hematocrit 30% (37% to 47%): This value is below the normal range, indicating anemia. Early pregnancy anemia can increase the risk of maternal fatigue, preterm birth, and low birth weight. The nurse should report this finding to the provider for further evaluation and possible iron supplementation.
D. RBC count 6 million/mm³ (4.2 to 6.1 million/mm³): This value is within the normal range for red blood cells. It does not indicate any immediate concern and does not require reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Required immunizations: Immunizations are a key aspect of primary prevention, as they protect children from preventable diseases before exposure occurs. Including information about required vaccines at the kindergarten level helps caregivers ensure children are protected and supports community health.
B. Nutrition for children who have diabetes: Nutrition management for children with diabetes is considered secondary or tertiary prevention, as it involves managing an existing condition rather than preventing disease onset. It is not the focus for primary prevention at a general health fair.
C. Emergency disaster planning: While disaster planning is important for safety, it is not classified as primary prevention of disease. It addresses preparedness rather than preventing the initial occurrence of a health condition.
D. Screening for a pediculosis breakout: Screening is a secondary prevention activity because it involves early detection of an existing condition (lice infestation). It does not prevent the initial occurrence of disease, so it is not a primary prevention topic.
Correct Answer is D
Explanation
Rationale:
A. Provide 60 mL (2 oz) of fluid intake every 5 min.: Following gastric bypass surgery, the stomach pouch is very small and cannot tolerate large or frequent volumes. Giving 60 mL every 5 minutes places the client at high risk for nausea, vomiting, dumping syndrome, and anastomotic complications. Fluid intake must be introduced slowly in small sips.
B. Ambulate the client 48 hr after the procedure.: Early ambulation is essential to prevent postoperative complications such as atelectasis, venous thromboembolism, and delayed return of bowel function. Waiting 48 hours is too long; clients should begin ambulating on the day of surgery or within the first 24 hours to promote circulation.
C. Provide a soft diet on the first postoperative day.: After gastric bypass surgery, the digestive system needs time to heal and cannot tolerate solid or semi-solid foods. Clients begin with clear liquids and progress gradually to pureed, soft, and then solid diets over several weeks.
D. Measure and compare abdominal girth daily.: Monitoring abdominal girth helps detect postoperative complications such as internal bleeding, leaks, or ileus, which may present with distention or increased abdominal size. Regular measurement provides early recognition of changes that require prompt intervention.
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