A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment.
Which of the following laboratory tests should the nurse plan to conduct?
1-hour glucose tolerance test.
Rubella titer.
Sexually transmitted disease test (STI test).
Group B strep culture.
The Correct Answer is A
Choice A rationale
The 1-hour glucose tolerance test is typically performed between 24 and 28 weeks of gestation to screen for gestational diabetes. This screening involves measuring the client's blood glucose level one hour after consuming a 50-gram glucose load. A normal result is generally considered to be a blood glucose level below 130-140 mg/dL.
Choice B rationale
Rubella titer is usually assessed early in pregnancy, ideally during the first prenatal visit, to determine the woman's immunity to rubella. If the woman is not immune, vaccination is typically offered postpartum to prevent infection in subsequent pregnancies, as rubella infection during pregnancy can cause serious congenital defects.
Choice C rationale
Sexually transmitted disease testing is ideally conducted at the initial prenatal visit to identify and treat any infections early in pregnancy, reducing the risk of transmission to the fetus and other complications. While repeat testing may be indicated based on risk factors, it is not a routine test specifically scheduled for the 24-week appointment for all clients.
Choice D rationale
Group B Streptococcus (GBS) culture is typically performed later in pregnancy, usually between 35 and 37 weeks of gestation, to determine if the woman is colonized with GBS. This is important for intrapartum management to prevent neonatal GBS infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A urinary output of 30 mL/hr is within the normal range for an adult, indicating adequate kidney perfusion and hydration status postpartum. Normal urine output is typically considered to be greater than 30 mL/hr.
Choice B rationale
Headache pain rated a 6 on a scale of 0 to 10 is a common complaint postpartum, especially after spinal anesthesia. While it requires assessment and management, it is not necessarily a sign of immediate life-threatening complication. Postpartum headaches can be related to hormonal shifts, dehydration, or the spinal anesthesia itself.
Choice C rationale
A blood pressure of 100/70 mm Hg is within the normal postpartum range for many women. While a decrease from pre-pregnancy levels can occur, this reading does not indicate an immediate critical issue. Normal postpartum blood pressure generally stabilizes around pre-pregnancy levels within a few days.
Choice D rationale
A respiratory rate of 10 breaths per minute is below the normal adult range of 12 to 20 breaths per minute. This bradypnea could indicate respiratory depression, a potential complication of spinal anesthesia, especially if opioid analgesics have been administered. Immediate intervention is required to assess the cause and ensure adequate oxygenation.
Correct Answer is ["A","B","C","E","F"]
Explanation
Choice A rationale
Hourly monitoring of deep tendon reflexes is crucial in clients receiving magnesium sulfate for severe preeclampsia. Magnesium sulfate acts as a central nervous system depressant, and diminished or absent deep tendon reflexes (normal range: 2+ to 4+) can indicate magnesium toxicity, necessitating immediate intervention to prevent serious complications like respiratory depression.
Choice B rationale
A urinary output of less than 30 mL per hour signals potential renal hypoperfusion, which can be exacerbated by severe preeclampsia and magnesium sulfate administration. Reduced kidney function can lead to the accumulation of magnesium, increasing the risk of toxicity. Prompt notification of the physician allows for timely adjustments in the treatment plan.
Choice C rationale
Calcium gluconate is the antidote for magnesium sulfate overdose. Having it readily available is essential in case the client exhibits signs of magnesium toxicity, such as respiratory depression, severe hypotension, or loss of reflexes. Prompt administration of calcium gluconate can reverse the effects of magnesium and prevent life-threatening complications.
Choice E rationale
Hourly monitoring of intake and output is vital to assess fluid balance and renal function in pregnant clients with severe preeclampsia receiving magnesium sulfate. Accurate measurement helps in detecting oliguria, a sign of worsening preeclampsia or magnesium toxicity, allowing for timely interventions to maintain adequate hydration and prevent complications.
Choice F rationale
Severe preeclampsia significantly impacts both renal and cardiac function due to widespread vasoconstriction and endothelial dysfunction. Close monitoring of these systems through laboratory tests (e.g., serum creatinine, BUN, electrolytes, ECG) and clinical assessments is essential to detect and manage potential complications such as acute kidney injury, heart failure, and arrhythmias.
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