A nurse is caring for a client who is pregnant.
Exhibits

Select the 3 actions that the nurse should plan to take

Encourage the client to limit carbohydrate intake to 40% of their daily calories.

Instruct the client to check a random blood glucose level once daily

Anticipate a prescription for metformin.

Conduct a non-stress test twice per week.

Answer and Explanation

Correct Answer : A,C,D

A. Encourage the client to limit carbohydrate intake to 40% of their daily calories. For clients with gestational diabetes, dietary modifications are a critical intervention. Limiting carbohydrate intake to 40% of daily calories can help regulate blood glucose levels.

B. Instruct the client to check a random blood glucose level once daily. The client should check fasting and postprandial blood glucose levels regularly (usually multiple times per day) to manage glucose control more effectively.

C. Anticipate a prescription for metformin. Given the elevated fasting blood glucose levels and high HbA1C (12%), this client may require pharmacological management to control blood sugar levels. Metformin is a common oral hypoglycemic agent used during pregnancy when diet and lifestyle changes are insufficient.

D. Conduct a non-stress test twice per week. Clients with uncontrolled gestational diabetes or poorly controlled blood sugar levels are at increased risk of fetal complications such as macrosomia, stillbirth, and preterm labor. A non-stress test (NST) twice a week helps monitor fetal well-being and detect early signs of distress.

E. Tell the client to refrain from exercise until after delivery. Exercise is generally recommended for clients with gestational diabetes unless contraindicated. Regular physical activity can help lower blood glucose levels and improve insulin sensitivity.

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Correct Answer is C

Explanation

A. "This is a positive sign of pregnancy." A positive sign of pregnancy includes objective evidence such as fetal heartbeat, fetal movement felt by the examiner, or visualizing the fetus on an ultrasound.

B. "This is a possible sign of pregnancy." Possible signs refer to physical changes that could indicate pregnancy but are not definitive, such as breast changes or uterine enlargement.

C. "This is a presumptive sign of pregnancy." Feeling fetal movement (quickening) is considered a presumptive sign because it is subjective and reported by the client, which may indicate pregnancy but is not definitive.

D. "This is a probable sign of pregnancy." Probable signs are objective signs observed by the examiner, such as a positive pregnancy test or Chadwick’s sign, but still not conclusive for pregnancy.

A. Assist the client into a side-lying position. B. Offer the client orange juice and repeat the assessment in 1 hr. C. Assure the client that the score is within the expected range. D. Administer oxygen and notify the provider.

Correct Answer is C

Explanation

A. Assist the client into a side-lying position. There is no indication that the client needs repositioning based on the biophysical profile score. A score of 10 is normal, indicating the fetus is healthy.

B. Offer the client orange juice and repeat the assessment in 1 hr. This would be indicated if the score was low or if fetal movement was not detected, which is not the case here.

C. Assure the client that the score is within the expected range. A biophysical profile score of 10 is considered normal, indicating the fetus is well-oxygenated and not experiencing distress. The nurse should reassure the client that the score is normal.

D. Administer oxygen and notify the provider. There is no indication of fetal distress requiring oxygen administration based on a score of 10.

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A nurse is caring for a client who is pregnant. Exhibits Select the 3 actions that the nurse should plan to take

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who tells the nurse that she thinks she might be pregnant because she is able to feel the baby move. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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A nurse is caring for a client who is pregnant.
Exhibits

Select the 3 actions that the nurse should plan to take