A client who is pregnant is scheduled for a contraction stress test (CST). Which of the following findings are indications for this procedure? (Select all that apply)
- A. Decreased fetal movement
- B. Intrauterine growth restriction (IUGR)
- C. Postmaturity
- D. All of the Above
Correct Answer: D
Rationale: The correct answer is D, All of the Above.
1. Decreased fetal movement indicates fetal distress, necessitating CST.
2. IUGR implies potential placental insufficiency, requiring CST evaluation.
3. Postmaturity increases risk of placental insufficiency, warranting CST.
Other choices are incorrect as they do not directly indicate the need for CST in a pregnant client.
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When developing an educational program for adolescents about nutrition during the third trimester of pregnancy, which of the following statements should be included?
- A. Consume three to four servings of dairy each day.
- B. Increase daily caloric intake by 600 to 700 calories.
- C. Limit daily sodium intake to less than 1 gram.
- D. Increase protein intake to 40 to 50 grams per day.
Correct Answer: A
Rationale: The correct answer is A: Consume three to four servings of dairy each day. During the third trimester of pregnancy, calcium needs increase to support the baby's bone development. Dairy products are a rich source of calcium. Adolescents are still growing themselves, so adequate calcium intake is crucial for both the mother and baby.
B: Increasing caloric intake by 600 to 700 calories is not specific to the third trimester and may lead to excessive weight gain, which can be harmful.
C: Limiting sodium intake to less than 1 gram is not necessary during pregnancy, and some sodium is required for maintaining fluid balance.
D: Increasing protein intake to 40 to 50 grams per day is important, but it is not specific to the third trimester and may vary based on individual needs.
A client in an obstetrical clinic is discussing using an IUD for contraception with a healthcare provider. Which of the following statements by the client indicates an understanding of the teaching?
- A. An IUD should be replaced annually during a pelvic exam.
- B. I cannot get an IUD until after I've had a child.
- C. I should plan on regaining fertility 5 months after the IUD is removed.
- D. I will check to ensure the strings of the IUD are still present after my periods.
Correct Answer: D
Rationale: The correct answer is D. Checking the strings of the IUD after periods ensures that the device is in place. This indicates understanding of IUD maintenance. Choice A is incorrect because IUDs usually last 3-10 years and do not need annual replacement. Choice B is incorrect because nulliparous women can also use IUDs. Choice C is incorrect as fertility typically returns quickly after IUD removal, not necessarily after 5 months.
A client who is at 8 weeks of gestation tells the nurse, 'I am not sure I am happy about being pregnant.' Which of the following responses should the nurse make?
- A. I will inform the provider that you are having these feelings.
- B. It is normal to have these feelings during the first few months of pregnancy.
- C. You should be happy that you are going to bring new life into the world.
- D. I am going to make an appointment with the counselor for you to discuss these thoughts.
Correct Answer: B
Rationale: Rationale for Correct Answer B: It is normal to have these feelings during the first few months of pregnancy.
1. Acknowledges client's emotions without judgment.
2. Validates the client's experience as common and normal.
3. Provides reassurance and support.
4. Encourages open communication.
Summary of Incorrect Choices:
A. Not necessary to escalate without client's consent.
C. Invalidates client's feelings and imposes expectations.
D. Implies assumption of severity and may be seen as intrusive.
When discussing intermittent fetal heart monitoring with a newly licensed nurse, which statement should a nurse include?
- A. Count the fetal heart rate for 15 seconds to determine the baseline.
- B. Auscultate the fetal heart rate every 5 minutes during the active phase of the first stage of labor.
- C. Count the fetal heart rate after a contraction to determine baseline changes.
- D. Auscultate the fetal heart rate every 30 minutes during the second stage of labor.
Correct Answer: C
Rationale: The correct answer is C because counting the fetal heart rate after a contraction helps determine baseline changes, which is essential for identifying fetal distress. This method allows for accurate assessment of fetal well-being in response to contractions. Choice A is incorrect as 15 seconds is not enough time to establish a baseline. Choice B is incorrect as auscultating every 5 minutes may not provide timely information during the active phase. Choice D is incorrect because auscultating every 30 minutes in the second stage may miss important changes in fetal status. Therefore, option C is the most appropriate choice for intermittent fetal heart monitoring.
A healthcare professional in a provider's office is reviewing the medical record of a client who is in her first trimester of pregnancy. Which of the following findings should the healthcare professional identify as a risk factor for the development of preeclampsia?
- A. Singleton pregnancy
- B. BMI of 20
- C. Maternal age of 32 years
- D. Pregestational diabetes mellitus
Correct Answer: D
Rationale: The correct answer is D: Pregestational diabetes mellitus. Preeclampsia is a condition characterized by high blood pressure and protein in the urine during pregnancy. Pregestational diabetes is a known risk factor for developing preeclampsia due to the underlying vascular and inflammatory changes associated with diabetes. In contrast, choices A, B, and C are not typically considered risk factors for preeclampsia. A singleton pregnancy (choice A) is a normal occurrence and not a risk factor for preeclampsia. A BMI of 20 (choice B) falls within the healthy weight range and is not a known risk factor for preeclampsia. Maternal age of 32 years (choice C) is also not considered a significant risk factor for preeclampsia in the absence of other factors.
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