A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history reveals she has a 7-year-old daughter who was born at 34 weeks gestation, a 2-year old son born at 39 weeks gestation, and a spontaneous abortion 1 year ago at 6 weeks gestation. Using the GTPAL method, the nurse would document her obstetric history as:
3-2-1-0-2
4-1-1-1-3
4-1-1-1-2
4-1-2-0-3
The Correct Answer is C
Choice A Reason: 3-2-1-0-2. This is an incorrect answer that underestimates the number of pregnancies and overestimates the number of preterm births. The client has had four pregnancies, not three. She has had one preterm birth, not two.
Choice B Reason: 4-1-1-1-3. This is an incorrect answer that overestimates the number of living children. The client has two living children, not three.
Choice C Reason 4-1-1-1-2. This is because the GTPAL method is a way of summarizing a woman's obstetric history using five numbers: G (gravida), T (term births), P (preterm births), A (abortions), and L (living children). Gravida is the number of pregnancies, regardless of outcome. Term births are deliveries after 37 weeks' gestation. Preterm births are deliveries between 20 and 37 weeks' gestation. Abortions are pregnancies that end before 20 weeks' gestation, either spontaneously or electively. Living children are the number of children who are alive at the time of assessment.
Choice D Reason: 4-1-2-0-3. This is an incorrect answer that overestimates the number of preterm births and living children, and underestimates the number of abortions. The client has had one preterm birth, not two. She has had one abortion, not zero. She has two living children, not three.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Obtain a bilirubin level. This is an incorrect answer that indicates an irrelevant and unnecessary nursing action for a newborn with tremors or jiteriness. Obtaining a bilirubin level is a nursing action that is indicated for a newborn with jaundice (yellowish discoloration of the skin and mucous membranes), which can occur due to increased bilirubin production or decreased bilirubin excretion. Jaundice does not cause tremors or jiteriness in newborns.
Choice B Reason: Place a pulse oximeter on the newborn. This is an incorrect answer that suggests an inappropriate and insufficient nursing action for a newborn with tremors or jiteriness. Placing a pulse oximeter on the newborn is a nursing action that measures oxygen saturation and heart rate, which can indicate hypoxia (low oxygen level) or distress in newborns. Hypoxia can cause tremors or jiteriness in newborns, but it is not the only or most likely cause. Placing a pulse oximeter on the newborn does not provide enough information to diagnose or treat hypoglycemia.
Choice C Reason: Obtain a blood glucose level. This is because tremors or jiteriness are common signs of hypoglycemia (low blood glucose) in newborns, which can occur due to various factors such as prematurity, maternal diabetes, infection, or cold stress. Hypoglycemia can cause neurological damage or death if not treated promptly and effectively. Obtaining a blood glucose level is a nursing action that has the highest priority for a newborn with tremors or jiteriness, as it can confirm the diagnosis and guide the treatment.
Choice D Reason: Take the newborn's vital signs. This is an incorrect answer that implies an inadequate and delayed nursing action for a newborn with tremors or jiteriness. Taking the newborn's vital signs is a nursing action that monitors temperature, pulse, respiration, and blood pressure, which can indicate general health status and stability in newborns. Taking the newborn's vital signs may reveal signs of hypoglycemia, such as hypothermia, tachycardia, tachypnea, or hypotension, but it is not a specific or definitive test for hypoglycemia. Taking the newborn's vital signs may also waste valuable time that could be used to obtain a blood glucose level and initiate treatment.
Correct Answer is D
Explanation
Choice A Reason: Applying Vaseline or lotion to newborn to maximize light absorption. This is an incorrect answer that indicates a contraindicated and harmful intervention that can interfere with phototherapy. Applying Vaseline or lotion to newborn can create a barrier or a reflective surface that can reduce the exposure and penetration of light to the skin, which can decrease the efficacy of phototherapy. Applying Vaseline or lotion to newborn can also cause skin irritation, infection, or burns, as it can trap heat and moisture under the light source.
Choice B Reason: Reducing the amount of fluid intake to 8 ounces daily. This is an incorrect answer that suggests a detrimental and dangerous intervention that can impair phototherapy. Reducing the amount of fluid intake to 8 ounces daily can cause dehydration, hypoglycemia, or electrolyte imbalance in newborns, which can worsen jaundice and increase the risk of complications such as kernicterus (brain damage due to high bilirubin levels). Reducing the amount of fluid intake to 8 ounces daily can also decrease the excretion of bilirubin through urine or stool, which can counteract the effect of phototherapy.
Choice C Reason: Keeping the newborn in the supine position. This is an incorrect answer that implies an incomplete and inadequate intervention that can limit phototherapy. Keeping the newborn in the supine position is a nursing action that involves placing the newborn on their back, which can expose their anterior body surface to light.
However, keeping the newborn in the supine position alone is not sufficient for phototherapy, as it does not expose their posterior body surface to light. The nurse should also reposition the newborn frequently to expose different body parts to light, such as their sides or abdomen.
Choice D Reason: Feeding every 3 hours to maximize intake of fluids and output. This is because feeding every 3 hours is a nursing intervention that can enhance the effectiveness and safety of phototherapy, which is a treatment that uses blue or white light to reduce the level of bilirubin in the blood. Bilirubin is a yellow pigment that is produced when red blood cells are broken down, which can cause jaundice (yellowish discoloration of the skin and mucous membranes) if it accumulates in excess. Phototherapy works by converting bilirubin into a water-soluble form that can be excreted through urine or stool. Feeding every 3 hours can increase the intake of fluids and calories, which can promote hydration, nutrition, and elimination of bilirubin.
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