Nokea
A client at 32-weeks gestation is admitted to the labor and delivery unit with complaints of severe headache, visual disturbances, and epigastric pain. The client's blood pressure is 150/100 mm Hg. What condition should the nurse suspect?
- A. Gestational hypertension.
- B. Preeclampsia.
- C. Eclampsia.
- D. Chronic hypertension.
Correct Answer: B
Rationale: Preeclampsia is characterized by hypertension, proteinuria, and symptoms such as headache, visual disturbances, and epigastric pain.
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The nurse states to the newly pregnant patient, 'Tell me how you feel about being pregnant.' Which communication technique is the nurse using with this patient?
- A. Clarifying
- B. Paraphrasing
- C. Reflection
- D. Structuring
Correct Answer: A
Rationale: The nurse is attempting to follow up and check the accuracy of the patient's message, which is clarifying.
When teaching a gravid client how to perform kick (fetal movement) counts which instruction should the nurse includes.
- A. Exercise for 15 before starting the counting to help increase fetal movement
- B. Count the movements once daily for one hour, before breakfast
- C. Avoid caffeinated drinks for 24 hours before conducting the kick test.
- D. If 10 kicks are not felt within 1 hr, drink orange juice and count for another hour.
Correct Answer: D
Rationale: Drinking orange juice can stimulate fetal movement if counts are low (D).
A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 7 cm, 100% effaced, and the fetus is at +1 station. The client begins to push forcefully with contractions. What action should the nurse take?
- A. Encourage the client to pant-blow during contractions.
- B. Assist the client to push with contractions.
- C. Prepare for an immediate delivery.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Pant-blow breathing helps prevent premature pushing before full dilation, reducing the risk of cervical edema.
When planning care for a laboring client, the nurse identifies the need to withhold solids food while the client is in labored. What is the most important reasons for this nursing intervention?
- A. Nausea occurs from analgesics used during labor
- B. Autonomic nervous system stimulation during labor decrease peristalsis
- C. An increased risk of aspiration can occur if general anesthesia is needed
- D. Gastric emptying time decreases during labor.
Correct Answer: C
Rationale: Aspiration risk (C) is a primary reason for withholding solid foods during labor.
Which guidance related to a healthy diet during pregnancy will the nurse provide to a patient in her 1st trimester?
- A. Every day you need to have at least 6 ounces of protein from sources such as meat, fish, eggs, beans, nuts, soybean products, and tofu.'
- B. High-dose vitamin A supplements will promote optimal vision while preventing a common cause of blindness in neonates.'
- C. Meals such as sushi with a cold deli salad made with raw sprouts combine high-fiber foods with protein sources to meet multiple nutritional needs.'
- D. Vitamin and mineral supplements can meet your nutrient needs if you have inadequate intake because of nausea or a sensation of fullness.'
Correct Answer: A
Rationale: Step 1: During pregnancy, protein is essential for the growth and development of the fetus, making option A correct.
Step 2: The other options are incorrect due to potential risks. High-dose vitamin A (Option B) can be harmful to the fetus.
Step 3: Consuming raw sprouts (Option C) poses a risk of foodborne illness, which can be dangerous during pregnancy.
Step 4: Relying solely on supplements (Option D) is not recommended as they may not provide all the necessary nutrients found in whole foods.
In summary, option A is correct as it emphasizes the importance of protein intake during pregnancy, while the other options pose potential risks or limitations in meeting nutritional needs.