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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.
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For the pregnant patient who is a vegan, what combination of foods will the nurse advise to meet the nutritional needs for all essential amino acids?
- A. Eggs and beans
- B. Fruits and vegetables
- C. Grains and legumes
- D. Vitamin and mineral supplements
Correct Answer: C
Rationale: The correct answer is C (Grains and legumes) because when combined, they provide all essential amino acids needed for a vegan pregnant patient. Grains are low in lysine but high in methionine, while legumes are high in lysine but low in methionine. By consuming both, the patient can achieve a complete protein profile. Choice A (Eggs and beans) is incorrect as vegans do not consume eggs. Choice B (Fruits and vegetables) lacks adequate protein and essential amino acids. Choice D (Vitamin and mineral supplements) is important for overall health but does not provide the necessary amino acids.
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicated that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in this client's record?
- A. 3-1-2-0-3
- B. 4-1-2-0-3
- C. 2-1-2-1-2
- D. 3-1-1-0-3
Correct Answer: D
Rationale: (D) describes the correct GTPAL. The client has been pregnant 3 times including the current pregnancy (G-3). She had one full-term infant (T-1). She also had a preterm (P-1) twin pregnancy (a multifetal gestation is considered one birth when calculating parity). There were no abortions (A-0), so this client has a total of 3 living children.
The nurse is assessing a patient's use of complementary and alternative therapies. Which should the nurse document as an alternative or complementary therapy practice?
- A. Practicing yoga daily
- B. Drinking green tea in the morning
- C. Taking omeprazole (Prilosec) once a day
- D. Using aromatherapy during a relaxing bath
Correct Answer: C
Rationale: Yoga, green tea, and aromatherapy are examples of complementary and alternative therapies.
The nurse's assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first?
- A. Position radiant warmer over the crib
- B. Assess the infants blood glucose level
- C. Nipple feed 1 ounce 1% glucose in water
- D. Place the infant in side-lying position
Correct Answer: A
Rationale: A radiant warmer (A) helps stabilize the infant's temperature and provides immediate warmth.
A patient in her fifth month of pregnancy asks the nurse, 'How many more calories should I be eating daily?' What is the correct response by the nurse?
- A. 180 more calories a day
- B. 340 more calories a day
- C. 452 more calories a day
- D. 500 more calories a day
Correct Answer: B
Rationale: The correct response is B: 340 more calories a day. During the second trimester, an additional 340 calories per day is recommended for pregnant women. This ensures proper nutrition for both the mother and the developing fetus. Option A (180 more calories) may not provide enough energy for the needs of pregnancy. Options C (452 more calories) and D (500 more calories) are excessive and could lead to unnecessary weight gain, which may pose risks during pregnancy. Option B strikes a balanced approach to support the increased energy demands of pregnancy without being excessive.