A nurse in a provider's office is testing capillary blood glucose for a client who has gestational diabetes. The result is 50 mg/dL (60 to 105 mg/dL). Which of the following actions should the nurse take?

Obtain a urine sample to test for

Perform a second capillary glucose test in 30 min

Give the client 120 mL (4 oz) of regular soda

Recommend transportation to an emergency department

Answer and Explanation

The Correct Answer is C

A. Obtain a urine sample to test for ketones. While ketone testing can be useful in cases of prolonged hypoglycemia or suspected diabetic ketoacidosis, it is not the priority action for immediate management of hypoglycemia. The nurse should first focus on raising the client's blood glucose level.
B. Perform a second capillary glucose test in 30 min. Delaying treatment by waiting 30 minutes could allow the blood glucose level to drop further, increasing the risk of more severe symptoms, such as confusion or loss of consciousness. Immediate intervention is needed to correct the low blood glucose.
C. Give the client 120 mL (4 oz) of regular soda. A blood glucose level of 50 mg/dL is below the normal range and requires prompt treatment. The best initial action is to provide a fast-acting carbohydrate, such as 4 oz of regular soda, fruit juice, or glucose tablets, to rapidly increase blood glucose levels. The nurse should then recheck the glucose level in 15 minutes to ensure it has returned to a safe range.
D. Recommend transportation to an emergency department. While severe hypoglycemia may require emergency care, this client is conscious and can take oral carbohydrates. If the hypoglycemia does not improve after initial treatment, further medical evaluation may be needed, but immediate emergency transport is not necessary at this stage.

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Correct Answer is B

Explanation

A. Take an over-the-counter antacid. Antacids are primarily used for heartburn, not for nausea and vomiting during pregnancy. While some antacids may provide mild relief, they are not the first-line recommendation for managing morning sickness. Instead, dietary and lifestyle modifications are preferred.
B. Eat dry, bland foods in the morning. Consuming dry, bland foods such as crackers or toast before getting out of bed can help manage nausea by stabilizing blood sugar levels and preventing an empty stomach, which can worsen symptoms. Eating small, frequent meals throughout the day can also help prevent nausea from returning.
C. Restrict fluids to 1,000 mL/day. Fluid restriction is not recommended, as adequate hydration is essential during pregnancy. Instead, clients experiencing nausea should sip fluids between meals rather than with meals to reduce gastric fullness and discomfort. Dehydration can worsen nausea and increase the risk of complications.
D. Increase intake of fresh fruits. While fresh fruits provide essential vitamins and hydration, they may not specifically alleviate nausea. Some acidic or high-fiber fruits can even trigger nausea in sensitive individuals. Instead, clients should focus on easily digestible foods and consume fluids separately from meals.

A. CBC B. Serum bilirubin C. Urinalysis of ketones D. Liver enzymes

Correct Answer is C

Explanation

A. CBC. A complete blood count (CBC) can help assess for anemia, infection, or hemoconcentration due to dehydration. However, it is not the priority test for hyperemesis gravidarum. The immediate concern is assessing the severity of dehydration and ketosis, which directly impact maternal and fetal health.
B. Serum bilirubin. Serum bilirubin levels are typically measured when liver dysfunction or hemolysis is suspected. Hyperemesis gravidarum is primarily a condition of severe nausea and vomiting, leading to dehydration and ketosis rather than liver impairment. Jaundice and abnormal bilirubin levels would be more indicative of conditions such as HELLP syndrome or cholestasis of pregnancy.
C. Urinalysis of ketones. The presence of ketones in urine indicates prolonged vomiting, dehydration, and inadequate carbohydrate intake, leading to ketosis. Since hyperemesis gravidarum can cause significant nutritional deficits, checking for ketonuria helps determine the severity of the condition and guides the need for IV fluids and nutritional support. This makes it the priority test.
D. Liver enzymes. Liver enzyme tests may be elevated in hyperemesis gravidarum but are not the most immediate concern. While abnormal liver function can occur, it is more commonly associated with conditions such as intrahepatic cholestasis of pregnancy or HELLP syndrome. Evaluating hydration status and ketosis takes precedence in the initial assessment.

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A nurse in a provider's office is testing capillary blood glucose for a client who has gestational diabetes. The result is 50 mg/dL (60 to 105 mg/dL). Which of the following actions should the nurse take?

Nursing Test Bank

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