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A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following questions should the nurse ask to assess the client’s dietary intake?
- A. How much protein do you eat in a day?
- B. Are you taking a Vitamin C supplement?
- C. Have you considered eating shellfish?
- D. When was the last time you ate meat?
Correct Answer: A
Rationale: The correct answer is A: How much protein do you eat in a day? This question is important because a vegan diet may lack sufficient protein, which is crucial for fetal development during pregnancy. Protein intake should be monitored to ensure the client is meeting their nutritional needs.
Incorrect choices:
B: Are you taking a Vitamin C supplement? - While Vitamin C is important, assessing protein intake is more critical for a vegan diet.
C: Have you considered eating shellfish? - Shellfish is not suitable for a vegan diet.
D: When was the last time you ate meat? - Irrelevant for a vegan client.
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A nurse is caring for a newborn who is 12 hr old and is experiencing jitteriness. Which of the following laboratory findings should the nurse identify as the priority?
- A. Blood glucose
- B. Total bilirubin
- C. Hemoglobin
- D. Blood calcium
Correct Answer: A
Rationale: The correct answer is A: Blood glucose. In a newborn experiencing jitteriness, the priority is to assess blood glucose levels as hypoglycemia is a common cause. Low blood glucose in a newborn can lead to seizures and long-term neurological damage. Monitoring blood glucose levels and promptly addressing any abnormalities is crucial. Total bilirubin (B) is important for assessing jaundice, not jitteriness. Hemoglobin (C) and blood calcium (D) are not typically related to jitteriness in a newborn.
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
- A. Place the client in a supine position for 30 min following the first dose of anesthetic solution.
- B. Administer 1000 mL of dextrose 5% in water prior to the first dose of anesthetic solution
- C. Monitor the client’s blood pressure every 5 min following the first dose of anesthetic solution.
- D. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. This is crucial because epidural anesthesia can cause hypotension, a common side effect. Monitoring the client's blood pressure closely allows for early detection of hypotension and prompt intervention to prevent potential complications like fetal distress. Placing the client in a supine position for 30 min (A) is incorrect as it can lead to hypotension; administering dextrose solution (B) is not necessary for epidural anesthesia; ensuring NPO status (D) is important for other procedures but not specifically for epidural anesthesia.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule an annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health department.
Correct Answer: C
Rationale: Correct Answer: C. Tell the client they will start medication for HIV immediately after delivery.
Rationale: Starting HIV medication immediately after delivery is crucial in preventing mother-to-child transmission of HIV. Antiretroviral therapy should be initiated during pregnancy to reduce the viral load and continued postpartum to protect the baby. This approach has been shown to significantly reduce the risk of transmission.
Summary of other choices:
A: Administering penicillin G is not directly related to managing HIV in pregnancy.
B: Annual pelvic examinations are important for overall health but not specific to managing HIV in pregnancy.
D: Reporting the client's condition to the health department may be necessary but does not address the immediate need for HIV medication.
E, F, G: No additional choices provided.
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hyperglycemia
- B. Bilateral crackles
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: The correct answer is C: Hypotension. Opioid analgesics can cause vasodilation, leading to a drop in blood pressure. The nurse should monitor for hypotension as a potential adverse effect, as this can result in dizziness and decreased perfusion. Hyperglycemia (A) is not typically associated with opioid analgesics. Bilateral crackles (B) are more indicative of fluid overload or pulmonary edema. Polyuria (D) is excessive urination and is not a common adverse effect of opioid analgesics.
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
- A. Temperature 37.4°C (99.3°F)
- B. WBC count 9,000/mm3
- C. Uterine tenderness
- D. Scant lochia
Correct Answer: C
Rationale: The correct answer is C: Uterine tenderness. Endometritis is an infection of the uterine lining, which causes inflammation and tenderness in the uterus. This finding is expected in a client with endometritis.
A: Temperature of 37.4°C is within normal range postpartum and not specific to endometritis.
B: WBC count of 9,000/mm3 is within normal range and may not be significantly elevated in endometritis.
D: Scant lochia may not be a specific finding for endometritis as lochia changes can vary postpartum.