A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?
"You will need to drink the glucose solution 2 hours prior to the test."
"Limit your carbohydrate intake for 3 days prior to the test."
"A blood glucose of 130 to 140 is considered a positive screening result.
"You will need to fast for 12 hours prior to the test
The Correct Answer is C
Choice A Reason:
Drinking the glucose solution 2 hours prior to the test is not standard for a 1-hour GTT. Instead, the glucose solution is usually consumed within a short timeframe, such as 5 minutes, and the blood is drawn 1 hour afterward.
Choice B Reason:
Limiting carbohydrate intake for 3 days prior to the test is not a requirement for a 1-hour GTT. However, it may be advised for a longer fasting period or a different type of glucose tolerance test.
Choice C Reason:
C. “A blood glucose of 130 to 140 is considered a positive screening result.”
In the 1-hour glucose tolerance test during pregnancy, a blood glucose level of 135 mg/dL or higher is considered a positive screening result. If this threshold is met, further testing (such as the 3-hour glucose tolerance test) is recommended to confirm or rule out gestational diabetes.
.
Choice D Reason:
Fasting for 12 hours prior to the test is inappropriate. For a 1-hour GTT, the client is not typically required to fast.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Left upper quadrant is incorrect. The left upper quadrant is less likely to be the area where the point of maximum intensity of the fetal heart is heard when the fetal position is left occipital anterior.
Choice B Reason:
Right upper quadrant is incorrect. The right upper quadrant is not the typical location for assessing fetal heart tones when the fetal position is left occipital anterior. The heart tones are generally heard more towards the left side.
Choice C Reason:
Left lower quadrant is correct. Placing the ultrasound transducer in the left lower quadrant is likely to provide the best detection of the fetal heart tones in the described fetal position.
Choice D Reason:
Right lower quadrant is incorrect. Similar to the right upper quadrant, the right lower quadrant is not the optimal location for assessing the fetal heart when the fetal position is left occipital anterior. The left side is typically where the point of maximum intensity is found.
Correct Answer is B
Explanation
Choice A Reason:
Placing a rolled towel beneath one of the client's hips may be helpful to tilt the client and alleviate pressure, but it is not the first action.
Choice B Reason:
Applying internal upward pressure to the presenting part using two gloved fingers is appropriate. This maneuver, known as "manual elevation of the presenting part," helps lift the presenting part off the prolapsed cord, preventing compression and maintaining blood flow to the fetus. This action should be performed while waiting for additional assistance and interventions.
Choice C Reason:
Administering oxygen is important for the well-being of the fetus, but the immediate focus is on relieving pressure on the umbilical cord.
Choice D Reason:
Increasing the infusion rate may be necessary later, but the immediate priority is to address the prolapsed cord and ensure fetal oxygenation.
4.A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse Include?
A. Place the shoulder harness in the slots above the newborn's shoulders.
B. Place the retainer clip at the level of the newborn's armpits.
C. Place the newborn at a 60° angle in the car seat.
D. Place the newborn in a blanket before securing them in the car seat.
Explanation
The correct answer is choice B
Choice A Reason:
Placing the shoulder harness in the slots above the newborn's shoulders is incorrect. The harness should be threaded through the slots at or below the baby's shoulders to provide proper protection.
Choice B Reason:
Placing the retainer clip at the level of the newborn's armpits is correct. This is a critical safety measure to ensure that the harness straps are positioned correctly on the newborn. Placing the retainer clip at the level of the armpits helps secure the harness straps over the baby's shoulders and prevents them from slipping off.
Choice C Reason:
Placing the newborn at a 60° angle in the car seat is not a standard recommendation. The car seat should be installed according to the manufacturer's instructions, and the baby should be placed in a semi-reclined position, typically at a 45° angle, to ensure proper support for the newborn's head and airway.
Choice D Reason:
Placing the newborn in a blanket before securing them in the car seat is not recommended. Extra padding, including bulky clothing or blankets, should not be placed under the harness straps as it can compromise the effectiveness of the restraint system. The baby should be dressed in thin layers, and if additional warmth is needed, a blanket can be placed over the baby after securing them in the car seat.
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