A nurse is reviewing the results of a 1-hr glucose screening test for a client who is at 24 weeks of gestation. The client's glucose value is 130 mg/dL. Which of the following actions should the nurse take?
Schedule the client for a routine 1-month appointment.
Instruct the client to return for a 3-hr oral glucose tolerance test.
Have the client perform home glucose monitoring for 1 week.
Repeat the 1 hr glucose testing in 1 week.
The Correct Answer is B
A) Incorrect- Scheduling a routine 1-month appointment is not appropriate given the elevated glucose value. A 1-hour glucose screening test value of 130 mg/dL indicates an elevated glucose level, which suggests the need for further testing to confirm or rule out gestational diabetes.
B) Correct - An elevated glucose value on the initial screening test requires confirmation through a more comprehensive test, such as the 3-hour oral glucose tolerance test.
C) Incorrect- Home glucose monitoring might be indicated for gestational diabetes but is not the next step after an elevated 1-hour glucose screening test.
D) Incorrect- Repeating the 1-hour glucose test in 1 week is not necessary; if the initial test is elevated, further testing is required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- A reddened area on the calf might indicate a potential blood clot (deep vein thrombosis), which is important to assess but may not be the highest priority.
B) Incorrect- Painful uterine contractions during breastfeeding can be a normal response due to oxytocin release during breastfeeding and might not require immediate reporting.
C) Correct - A urinary output of 125 mL in 4 hours is significantly low and could indicate inadequate fluid intake, potential urinary retention, or other issues that need prompt attention. It is a sign of impaired renal function. This could indicate dehydration, blood loss, infection, or kidney injury. The nurse should assess the client's fluid intake and output, vital signs, urine specific gravity, and serum electrolyte levels. The nurse should also monitor the client for signs of hypovolemia, such as tachycardia, hypotension, and decreased skin turgor.
D) Incorrect- Changing a perineal pad every 2 hours is within the normal range for postpartum bleeding and might not require immediate reporting.
Correct Answer is A
Explanation
A) Correct - Encouraging the client to void often is important, as a full bladder can increase discomfort and interfere with labor progress.
B) Incorrect- Remaining awake between contractions might not directly address pain management strategies.
C) Incorrect- Position changes can help with pain management, so minimizing them would not be appropriate.
D) Incorrect- The presence of a support person is often encouraged during labor, and there is no need to limit their time in the room.
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