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Which patient is most at risk for a low-birth-weight infant?
- A. 22-year-old, 60 inches tall, normal prepregnant weight
- B. 18-year-old, 64 inches tall, body mass index is <18.5
- C. 30-year-old, 78 inches tall, prepregnant weight is 15 lb above the norm
- D. 35-year-old, 75 inches tall, total weight gain in previous pregnancies was 33 lb
Correct Answer: B
Rationale: The correct answer is B because a low body mass index (<18.5) indicates underweight, which is a risk factor for delivering a low-birth-weight infant. Underweight individuals may have inadequate nutrition and lower reserves for a healthy pregnancy.
Choice A is less likely as the patient has a normal prepregnant weight. Choice C's prepregnant weight being above the norm suggests a healthy weight. Choice D's total weight gain in previous pregnancies being 33 lb indicates a healthy weight maintenance during pregnancy.
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A nurse is working with an active labor patient who is in preterm labor and has been designated as high risk. The patient is very apprehensive and asks the nurse, 'Is everything going to be all right?' The nurse replies, 'Yes, everything will be okay.' Following delivery via an emergency cesarean birth, the newborn undergoes resuscitation and does not survive. The patient is distraught over the outcome and blames the nurse for telling her that everything would be okay. Which ethical principle did the nurse violate?
- A. Autonomy
- B. Fidelity
- C. Beneficence
- D. Accountability
Correct Answer: B
Rationale: Fidelity involves keeping promises and being truthful; the nurse violated this principle by making an unrealistic promise.
A pregnant woman of normal weight enters her 13th week of pregnancy. If the patient eats and exercises as directed, what will the nurse anticipate as the ongoing weight gain for the remaining trimesters?
- A. 0.3 lb every week
- B. 1 lb every week
- C. 1.8 lb every week
- D. 2 lb every week
Correct Answer: B
Rationale: The correct answer is B: 1 lb every week. During the second and third trimesters, a pregnant woman is expected to gain about 1 lb per week on average. This weight gain is important for the healthy development of the baby and to support the mother's changing body. Gaining weight too slowly can lead to complications, while gaining too quickly can also have negative effects. Choices A, C, and D are incorrect because they suggest weight gain rates that are either too low or too high for a healthy pregnancy. It is crucial for the nurse to educate the patient on the importance of appropriate weight gain throughout the remaining trimesters to ensure the well-being of both the mother and the baby.
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is:
- A. Shortness of breath
- B. Joint pain
- C. A persistent cold
- D. Organomegaly
Correct Answer: C
Rationale: Respiratory tract infections commonly occur in the pediatric population. However, the child with AIDS has a decreased ability to defend the body against these infections and often the presenting symptom of a child with AIDS is a persistent cold (C).
In teaching a pregnant adolescent about nutrition, what should the nurse include in the care plan?
- A. Determine the weight gain needed to meet adolescent growth and add 35 lb.
- B. Suggest that she does not eat at fast food restaurants to avoid foods of poor nutritional value.
- C. Realize that most adolescents are unwilling to make dietary changes during pregnancy.
- D. Emphasize the need to eliminate common teen snack foods because they are too high in fat and sodium.
Correct Answer: A
Rationale: Rationale for Correct Answer A: The correct answer is A because it addresses the specific nutritional needs of a pregnant adolescent by considering her growth and weight gain requirements. It is essential to determine the appropriate weight gain based on the adolescent's pre-pregnancy weight and BMI to ensure a healthy pregnancy. Adding a standard amount (usually around 35 lb) on top of the recommended weight gain for adolescents accounts for the additional needs of the growing fetus.
Summary of Incorrect Choices:
B: This choice focuses on avoiding fast food restaurants but does not address the specific nutritional needs of a pregnant adolescent.
C: Assuming that most adolescents are unwilling to make dietary changes is a generalization and does not provide tailored guidance for the individual's needs.
D: While emphasizing the need to eliminate unhealthy snacks is important, it does not address the overall nutritional requirements and weight gain needed for a pregnant adolescent.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?
- A. Deep tendon reflexes 2+
- B. Blood pressure 140/90
- C. Respiratory rate 18/minute
- D. Urine output 90 ml/4 hours
Correct Answer: D
Rationale: Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.