Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing laboratory results from a client who is at 28 weeks of gestation and has gestational diabetes. The nurse notes that blood glucose levels taken 1 hr following a meal range from 145 mg/dL to 162 mg/dL over the past week. Which of the following actions should the nurse take?
A. Schedule a 3-hr oral glucose tolerance test.
A 3-hour OGTT is used for the initial diagnosis of gestational diabetes. This client is already diagnosed, so repeating it is unnecessary.
B. Tell the client to increase carbohydrates to 65% of daily nutritional intake.
Increasing carbohydrates to 65% of daily nutritional intake is not the appropriate action in this situation. It may lead to further elevation of blood glucose levels, which can be detrimental for a client with gestational diabetes. The goal is to manage blood glucose levels and prevent complications, so recommending a higher carbohydrate intake would be counterproductive.
C. Obtain an HbA1c.
Obtaining an HbA1c (glycated hemoglobin) is not the most suitable action in this scenario. HbA1c provides an average of the blood glucose levels over the past few months, which is more helpful for diagnosing and monitoring chronic diabetes, rather than gestational diabetes, which is temporary and occurs during pregnancy. An OGTT is a more appropriate test for gestational diabetes assessment.
D. Reinforce instruction about insulin administration.
In gestational diabetes, the goal for 1-hour postprandial glucose is <140 mg/dL. This client’s results (145–162 mg/dL) are above target, indicating inadequate control. Reinforcing insulin therapy and adherence is the priority to protect both mother and fetus from complications (macrosomia, hypoglycemia at birth, preeclampsia).
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Maternity Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
The nurse should schedule a 3-hour oral glucose tolerance test (OGTT) for the client because the blood glucose levels taken 1 hour following a meal are higher than the expected range for gestational diabetes. This test will help to diagnose and assess the client's glucose tolerance and determine if there is gestational diabetes or any other potential glucose regulation issues.
Choice B rationale:
Increasing carbohydrates to 65% of daily nutritional intake is not the appropriate action in this situation. It may lead to further elevation of blood glucose levels, which can be detrimental for a client with gestational diabetes. The goal is to manage blood glucose levels and prevent complications, so recommending a higher carbohydrate intake would be counterproductive.
Choice C rationale:
Obtaining an HbA1c (glycated hemoglobin) is not the most suitable action in this scenario. HbA1c provides an average of the blood glucose levels over the past few months, which is more helpful for diagnosing and monitoring chronic diabetes, rather than gestational diabetes, which is temporary and occurs during pregnancy. An OGTT is a more appropriate test for gestational diabetes assessment.
Choice D rationale:
Reinforcing instruction about insulin administration is not warranted at this point since there is no information indicating that the client is currently on insulin therapy. Additionally, using insulin as the first step in the management of gestational diabetes is not common practice. Lifestyle modifications, dietary changes, and other measures are usually attempted first.
Similar Questions
A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect?
A. Severe nausea and vomiting.
Severe nausea and vomiting are not indicative of an ectopic pregnancy. While nausea and vomiting are common symptoms in early pregnancy, they are not specific to ectopic pregnancies. These symptoms are more likely associated with typical pregnancy changes.
B. Pelvic pain.
Pelvic pain is a crucial finding that the nurse should expect in a possible ectopic pregnancy. As the pregnancy implants outside of the uterus, usually in the fallopian tube, it can cause sharp and severe pain in the pelvic region. This pain may be unilateral and can be accompanied by shoulder pain due to blood or fluid irritating the diaphragm.
C. Uterine enlargement greater than expected for gestational age.
Uterine enlargement greater than expected for gestational age is not likely in an ectopic pregnancy. In fact, uterine enlargement may not be noticeable at all in an ectopic pregnancy since the embryo is not developing in the uterus.
D. Copious vaginal bleeding.
Copious vaginal bleeding is more commonly associated with miscarriages or other complications in intrauterine pregnancies. In an ectopic pregnancy, vaginal bleeding may occur, but it is typically lighter and often described as spotting.
Full Explanation
Choice A rationale:
Severe nausea and vomiting are not indicative of an ectopic pregnancy. While nausea and vomiting are common symptoms in early pregnancy, they are not specific to ectopic pregnancies. These symptoms are more likely associated with typical pregnancy changes.
Choice B rationale:
Pelvic pain is a crucial finding that the nurse should expect in a possible ectopic pregnancy. As the pregnancy implants outside of the uterus, usually in the fallopian tube, it can cause sharp and severe pain in the pelvic region. This pain may be unilateral and can be accompanied by shoulder pain due to blood or fluid irritating the diaphragm.
Choice C rationale:
Uterine enlargement greater than expected for gestational age is not likely in an ectopic pregnancy. In fact, uterine enlargement may not be noticeable at all in an ectopic pregnancy since the embryo is not developing in the uterus.
Choice D rationale:
Copious vaginal bleeding is more commonly associated with miscarriages or other complications in intrauterine pregnancies. In an ectopic pregnancy, vaginal bleeding may occur, but it is typically lighter and often described as spotting.
A nurse is assisting with monitoring a client who has preeclampsia and is receiving magnesium sulfate. The client's respiratory rate is 8/min. Which of the following should the nurse administer?
A. Calcium gluconate.
The correct answer is A. Calcium gluconate. The nurse should administer calcium gluconate in this situation because the client's respiratory rate is 8/min, which indicates respiratory depression. Magnesium sulfate is known to cause respiratory depression as a side effect, and calcium gluconate is the antidote for magnesium sulfate toxicity. Calcium gluconate works by antagonizing the effects of magnesium on the neuromuscular junction and restoring normal respiratory function. Prompt administration of calcium gluconate can help reverse the respiratory depression and prevent further complications.
B. Naloxone.
Naloxone. Naloxone is not the correct choice in this scenario. Naloxone is an opioid antagonist and is used to reverse the effects of opioids in cases of opioid overdose. Since the client is receiving magnesium sulfate, which is not an opioid, naloxone would not be effective in reversing the respiratory depression caused by magnesium sulfate. Administering naloxone in this situation would not address the underlying cause and may not improve the client's condition.
C. Flumazenil.
Flumazenil. Flumazenil is not the correct choice in this situation. Flumazenil is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines in cases of benzodiazepine overdose. Since the client is not receiving benzodiazepines but rather magnesium sulfate, flumazenil would not be effective in treating the respiratory depression caused by magnesium sulfate. Using flumazenil in this context would not be appropriate and could potentially lead to adverse effects.
D. Protamine sulfate.
Protamine sulfate. Protamine sulfate is not the correct choice in this scenario. Protamine sulfate is an antidote for heparin overdose, not for magnesium sulfate toxicity. It works by neutralizing the effects of heparin and preventing further anticoagulation. Since the client's issue is respiratory depression caused by magnesium sulfate, administering protamine sulfate would not be helpful and would not address the primary problem.
Full Explanation
Choice A rationale :
The correct answer is A. Calcium gluconate. The nurse should administer calcium gluconate in this situation because the client's respiratory rate is 8/min, which indicates respiratory depression. Magnesium sulfate is known to cause respiratory depression as a side effect, and calcium gluconate is the antidote for magnesium sulfate toxicity. Calcium gluconate works by antagonizing the effects of magnesium on the neuromuscular junction and restoring normal respiratory function. Prompt administration of calcium gluconate can help reverse respiratory depression and prevent further complications.
Choice B rationale
Naloxone. Naloxone is not the correct choice in this scenario. Naloxone is an opioid antagonist and is used to reverse the effects of opioids in cases of opioid overdose. Since the client is receiving magnesium sulfate, which is not an opioid, naloxone would not be effective in reversing the respiratory depression caused by magnesium sulfate. Administering naloxone in this situation would not address the underlying cause and may not improve the client's condition.
Choice C rationale
Flumazenil. Flumazenil is not the correct choice in this situation. Flumazenil is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines in cases of benzodiazepine overdose. Since the client is not receiving benzodiazepines but rather magnesium sulfate, flumazenil would not be effective in treating the respiratory depression caused by magnesium sulfate. Using flumazenil in this context would not be appropriate and could potentially lead to adverse effects.
Choice D rationale
Protamine sulfate. Protamine sulfate is not the correct choice in this scenario. Protamine sulfate is an antidote for heparin overdose, not for magnesium sulfate toxicity. It works by neutralizing the effects of heparin and preventing further anticoagulation. Since the client's issue is respiratory depression caused by magnesium sulfate, administering protamine sulfate would not be helpful and would not address the primary problem.
A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?
A. Abdominal pain with minimal red vaginal bleeding.
Abdominal pain with minimal red vaginal bleeding may not be as concerning as other options. While it could be a sign of placenta previa, it is not as specific or significant as the finding in Choice B.
B. A large amount of bright red vaginal bleeding without pain.
A large amount of bright red vaginal bleeding without pain is a significant finding that is highly suggestive of placenta previa. Placenta previa occurs when the placenta partially or completely covers the cervix, and vaginal bleeding is a common symptom. The bright red colour indicates active bleeding, and the absence of pain is noteworthy as placenta previa bleeding is typically painless.
C. Severe abdominal pain with increasing fundal height.
Severe abdominal pain with increasing fundal height is not a typical sign of placenta previa. While abdominal pain can be associated with various pregnancy complications, it is not a specific finding for this condition.
D. Intermittent abdominal pain following the passage of bloody mucus.
Intermittent abdominal pain following the passage of bloody mucus could be related to other issues, such as preterm labor or cervical changes. While bleeding may be present in placenta previa, the pain and passage of mucus are not characteristic features of this condition.
Full Explanation
Choice A rationale:
Abdominal pain with minimal red vaginal bleeding may not be as concerning as other options. While it could be a sign of placenta previa, it is not as specific or significant as the finding in Choice B.
Choice B rationale:
A large amount of bright red vaginal bleeding without pain is a significant finding that is highly suggestive of placenta previa. Placenta previa occurs when the placenta partially or completely covers the cervix, and vaginal bleeding is a common symptom. The bright red colour indicates active bleeding, and the absence of pain is noteworthy as placenta previa bleeding is typically painless.
Choice C rationale:
Severe abdominal pain with increasing fundal height is not a typical sign of placenta previa. While abdominal pain can be associated with various pregnancy complications, it is not a specific finding for this condition.
Choice D rationale:
Intermittent abdominal pain following the passage of bloody mucus could be related to other issues, such as preterm labor or cervical changes. While bleeding may be present in placenta previa, the pain and passage of mucus are not characteristic features of this condition.