Nokea
A diabetic client delivers a full-term large for gestation-age (LGA) infant who is jittery. What action should the nurse take first?
- A. Administer oxygen
- B. Feed the infant glucose water (10%)
- C. Obtain a blood glucose level
- D. Decrease environment stimuli
Correct Answer: C
Rationale: Jitteriness in LGA infants suggests hypoglycemia, so obtaining a blood glucose level (C) is the priority.
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The nurse is conducting a prenatal nutrition education class for a group of nursing students. Which statement best describes the condition known as pica?
- A. Iron-deficiency anemia
- B. Intolerance to milk products
- C. Ingestion of nonfood substances
- D. Episodes of anorexia and vomiting
Correct Answer: C
Rationale: The correct answer is C: Ingestion of nonfood substances. Pica is a condition where individuals have a persistent craving to eat items that are not considered food, such as dirt, clay, or ice. This behavior can be seen in pregnant women due to nutritional deficiencies or psychological factors. Choices A, B, and D are incorrect because they do not accurately describe pica. Iron-deficiency anemia (A) is a condition related to low iron levels in the blood, intolerance to milk products (B) is a lactose intolerance issue, and episodes of anorexia and vomiting (D) are symptoms of eating disorders, not pica.
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.
A patient postdelivery is concerned about getting back to her prepregnancy weight as soon as possible. She had only gained 15 lb during her pregnancy. Which assessment factor would be of concern at her 6-week postpartum checkup?
- A. Patient has lost 30 lb during the 6-week period prior to her scheduled checkup.
- B. Patient states that she is eating healthy and limiting intake of processed foods.
- C. Patient relates increased consumption of fruits and vegetables in her diet postbirth.
- D. Patient has resumed her usual exercise pattern of walking around the neighborhood for 10 minutes each night.
Correct Answer: A
Rationale: The correct answer is (A) because losing 30 lb in the 6-week postpartum period is concerning as it is excessive and may indicate underlying health issues like hyperthyroidism or inadequate nutrition. This rapid weight loss can also affect the mother's energy levels, milk production, and overall health.
Choice (B) is incorrect as eating healthy and limiting processed foods is a positive behavior that supports weight management. Choice (C) is also incorrect as increased consumption of fruits and vegetables is beneficial for overall health. Choice (D) is incorrect because resuming a light exercise routine like walking is generally encouraged postpartum, as long as it is done safely and does not lead to excessive strain.
An obviously pregnant woman walks into the hospital's emergency department entrance shouting. 'Help me! Help me! My baby is coming! I'm so afraid!' The nurse determines if delivery is indeed imminent, what action is most important for the nurse to take?
- A. Determine the gestational age of fetus
- B. Assess the amount and color of the amniotic fluid
- C. Obtain peripheral IV access and begin administration of IV fluids
- D. Provide clear concise instructions in a calm, deliberate manner
Correct Answer: D
Rationale: Providing clear instructions (D) helps manage the situation calmly and effectively.
The nurse is caring for a laboring client who is GBS+ (Group B streptococcus). Which immediate treatment is indicated for this client?
- A. Administration of Pitocin
- B. Artificial rupture of the membrane
- C. Amnioinfusion for the baby
- D. Administration of antibiotics
Correct Answer: D
Rationale: Antibiotics (D) are administered to GBS+ mothers to prevent neonatal infection.