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

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is C. Assess the fetal heart rate.

A. Providing clean, dry underpads is important for maintaining cleanliness and comfort, but it is not the priority immediately following an amniotomy.

B. Monitoring the client's temperature is a consideration but is not the priority immediately following an amniotomy. Assessing the fetal well-being takes precedence.

C. Assessing the fetal heart rate is the priority action.

Following an amniotomy, there is a risk of cord prolapse or compression, and assessing the fetal heart rate helps detect any signs of fetal distress or compromise.

D. Assessing the odor of the amniotic fluid may be relevant, but it is not the immediate priority after an amniotomy. Focusing on fetal well-being is crucial.

A. Determine respiratory function. B. Increase the TV fluid rate. C. Access emergency medications from cart D. Collect a maternal blood sample for coagulopathy studies

Correct Answer is A

Explanation

The correct answer is A.

A. Determine respiratory function: The priority is to assess the client's airway, breathing, and circulation (ABCs). If the client becomes unresponsive, the nurse should quickly assess whether the airway is clear, check for breathing, and determine if there is a pulse. This initial assessment is crucial for identifying and addressing any immediate life-threatening issues.

B. Increase the TV fluid rate: While fluid administration may be necessary in certain situations, it is not the first priority when a client becomes unresponsive. Assessing respiratory function and circulation takes precedence to address immediate life-threatening concerns.

C. Access emergency medications from the cart: Accessing emergency medications may be necessary, but it should occur after the initial assessment of the client's airway, breathing, and circulation. Administering medications without first assessing the client's ABCs may delay appropriate interventions.

D. Collect a maternal blood sample for coagulopathy studies: This action is important for assessing coagulation status, but it is not the first priority when a client becomes unresponsive. The immediate focus should be on ensuring the client has a patent airway, is breathing, and has a pulse.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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