A nurse is reinforcing teaching to a client who is pregnant regarding a 1-hr glucose tolerance test (GTT). Which of the following statements by the client indicates an understanding of the test?

"This test is to check if my baby has diabetes.”

"If the result is higher than normal, I will need to be on insulin the rest of my life.”

"If I forget and eat before the test, then I won't be able to have the test done.”

"If the results are high, then I need another test to see if I have gestational diabetes.”

Answer and Explanation

The Correct Answer is D

Choice A reason:

The client stating, "This test is to check if my baby has diabetes,” indicates a misunderstanding of the purpose of the 1-hr glucose tolerance test (GTT). The test is performed to screen for gestational diabetes in the mother, not to check the baby's diabetes status. Rationale: Gestational diabetes is a condition where high blood sugar levels develop during pregnancy, and it can affect both the mother and the baby's health.

Choice B reason:

The client mentioning, "If the result is higher than normal, I will need to be on insulin the rest of my life,” demonstrates a misconception about the implications of the 1-hr GTT. The 1-hr GTT is a preliminary screening test, and if the results are higher than normal, it indicates the need for further evaluation, but it does not immediately mean a lifetime dependence on insulin. Rationale: Insulin therapy may be required for managing gestational diabetes in some cases, but not necessarily for the rest of the mother's life.

Choice C reason:

The client saying, "If I forget and eat before the test, then I won't be able to have the test done,” indicates a misunderstanding of the test procedure. The 1-hr GTT requires fasting before the test, typically for 8 to 14 hours, to get accurate results. However, if the client mistakenly eats before the test, it doesn't mean they cannot have the test done at all; they may need to reschedule it after an appropriate fasting period. Rationale: Fasting is crucial for accurate glucose level measurement during the test.

Choice D reason:

The client stating, "If the results are high, then I need another test to see if I have gestational diabetes,” demonstrates a correct understanding of the 1-hr GTT. If the initial screening test shows elevated glucose levels, further testing, such as the 3-hour glucose tolerance test (GTT), is required to confirm the diagnosis of gestational diabetes. Rationale: The 3-hour GTT is a more comprehensive diagnostic test used to confirm or rule out gestational diabetes.

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Correct Answer is C

Explanation

Birth weight has doubled.

Choice A reason:

The nurse should not expect a positive Babinski sign in a 4-year-old child during a well-child visit. The Babinski sign is a reflex seen in infants up to about 1 year of age and disappears as the nervous system matures. Its presence in a 4-year-old would be abnormal and may indicate neurological issues.

Choice B reason:

The nurse should not expect birth height to double in a 4-year-old child during a well-child visit. While children do experience significant growth in their early years, it is unlikely that birth height will have doubled by the age of 4. Doubling of birth height would be an atypical finding.

Choice C reason:

The correct choice. The nurse should expect that the child's birth weight has doubled during a well-child visit. From birth to age 4, children typically experience substantial weight gain, and doubling of birth weight is a common milestone in healthy development.

Choice D reason:

The nurse should not expect the presence of permanent teeth in a 4-year-old child during a well-child visit. Permanent teeth typically begin to emerge around 6 years of age and continue to erupt over the following years. The appearance of permanent teeth at age 4 would be premature and unusual.

A. Advise the client that most new mothers experience these feelings. B. Ask the client if they have had thoughts about harming their infant. C. Explain to the client they are experiencing the "baby blues.” D. Take the client to the emergency department.

Correct Answer is B

Explanation

Choice B reason: The nurse should ask the client if they have had thoughts about harming their infant. This is a crucial action because the client's statement suggests they may be experiencing feelings of inadequacy and self-doubt as a mother, which could potentially lead to more serious thoughts or actions. By directly asking about thoughts of harming the baby, the nurse can assess the client's mental and emotional state more thoroughly and determine if there is a risk of harm to the infant.

Choice A reason:

The nurse should advise the client that most new mothers experience these feelings. This response acknowledges the client's feelings of inadequacy and normalizes their experience, letting them know that it is common for new mothers to have doubts and insecurities. This validation can help the client feel less alone and more understood, promoting a therapeutic nurse-client relationship.

Choice C reason:

The nurse should explain to the client that they are experiencing the "baby blues.” This is a valid option because the client's statement indicates they may be experiencing mood swings, sadness, and emotional sensitivity, which are typical symptoms of the baby blues. Providing this information can help the client understand that these feelings are transient and often related to hormonal changes after childbirth.

Choice D reason:

Taking the client to the emergency department is not warranted based solely on the information provided. The client's statement does not indicate an immediate danger to themselves or their baby. However, if during the assessment (including choice B), the nurse identifies any signs of potential harm to the infant or the client, further action may be necessary, such as involving appropriate mental health professionals or support services.

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A nurse is reinforcing teaching to a client who is pregnant regarding a 1-hr glucose tolerance test (GTT). Which of the following statements by the client indicates an understanding of the test?

Nursing Test Bank

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Explanation

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Correct Answer is B

Explanation

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