Nokea
A client who is 12 weeks pregnant and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include in the teaching?
- A. You should eat foods high in protein before bedtime.
- B. You should avoid consuming liquids with your meals.
- C. You should eat three large meals per day.
- D. You should consume caffeine to help with nausea.
Correct Answer: B
Rationale: The correct answer is B: 'You should avoid consuming liquids with your meals.' This advice is essential because avoiding drinking liquids with meals can help prevent overdistension of the stomach, which can worsen nausea. Option A is incorrect because eating foods high in protein before bedtime may not directly address the issue of nausea and vomiting. Option C is incorrect as eating three large meals a day may exacerbate nausea due to overeating or having an empty stomach for an extended period. Option D is incorrect as consuming caffeine can actually worsen nausea in pregnant clients.
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A client who is postpartum reports abdominal cramping during breastfeeding. Which of the following actions should the nurse take?
- A. Administer ibuprofen
- B. Administer oxytocin
- C. Place a warm compress on the client's abdomen
- D. Assist the client to change positions
Correct Answer: A
Rationale: Abdominal cramping during breastfeeding is common due to the release of oxytocin. Ibuprofen, an analgesic, is suitable for relieving discomfort. Administering oxytocin is unnecessary and may exacerbate the cramping. Placing a warm compress may not address the underlying cause of the cramping. Changing positions may provide temporary relief but does not address the cause of the cramping.
A nurse is assessing a client who is at 28 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?
- A. 1+ proteinuria
- B. Blood pressure 144/92 mm Hg
- C. Respiratory rate 22/min
- D. Urine output 20 mL/hr
Correct Answer: D
Rationale: The nurse should report a urine output of 20 mL/hr. This finding can indicate decreased renal perfusion and possible development of preeclampsia, which is a severe complication of gestational hypertension. Inadequate urine output can suggest compromised kidney function and impaired maternal and fetal well-being. Options A, B, and C are within normal limits for a client with gestational hypertension and may not require immediate reporting to the provider.
A healthcare provider is assessing a newborn who is 12 hours old. Which of the following findings should the provider report?
- A. Respiratory rate 50/min
- B. Blood glucose 30 mg/dL
- C. Blood pressure 60/40 mm Hg
- D. Heart rate 140/min
Correct Answer: B
Rationale: A blood glucose level of 30 mg/dL in a newborn is significantly low and indicates hypoglycemia, which can be dangerous in a newborn. Hypoglycemia in a newborn can lead to neurological issues and requires immediate attention. The other findings provided, such as a respiratory rate of 50/min, blood pressure of 60/40 mm Hg, and a heart rate of 140/min, are within normal ranges for a newborn and do not require immediate reporting unless accompanied by clinical signs of distress.
A nurse is preparing to administer Rh immune globulin to a client who is 28 weeks gestation. The nurse should understand that Rh immune globulin is administered to prevent which of the following?
- A. Rh incompatibility
- B. Severe preeclampsia
- C. Placental abruption
- D. Erythroblastosis fetalis
Correct Answer: A
Rationale: The correct answer is A: Rh incompatibility. Rh immune globulin is administered to prevent the formation of antibodies in clients who are Rh-negative and have been exposed to Rh-positive fetal blood. Severe preeclampsia (choice B) is a condition characterized by high blood pressure and signs of damage to organs, not prevented by Rh immune globulin. Placental abruption (choice C) is the separation of the placenta from the uterine wall, not prevented by Rh immune globulin. Erythroblastosis fetalis (choice D) is a condition where maternal antibodies attack fetal red blood cells due to Rh incompatibility, which Rh immune globulin helps prevent.
A nurse is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Client reports constipation
- B. Client reports swelling in the face
- C. Client reports heartburn
- D. Client reports frequent urination
Correct Answer: B
Rationale: The correct answer is B because facial swelling can indicate preeclampsia, a serious condition during pregnancy that requires immediate medical attention. Constipation (choice A), heartburn (choice C), and frequent urination (choice D) are common discomforts during pregnancy and are not typically indicative of a serious complication like preeclampsia at 32 weeks of gestation.