Nokea
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will eat foods that taste good instead of balancing my meals.
- B. I will avoid having a snack before I go to bed each night.
- C. I will have a cup of hot tea with each meal.
- D. I will eliminate products that contain dairy from my diet.
Correct Answer: A
Rationale: The correct answer is A. By stating she will eat foods that taste good instead of balancing meals, the client demonstrates understanding of the need to prioritize eating to manage hyperemesis gravidarum. This choice indicates she recognizes the importance of maintaining adequate nutrition despite food aversions. Choice B is incorrect as avoiding bedtime snacks may worsen nausea. Choice C is incorrect as caffeine in tea can exacerbate nausea. Choice D is incorrect as dairy products are important for calcium and protein intake during pregnancy.
You may also like to solve these questions
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is Indicated or contraindicated for the newborn
- A. Educate the parents to begin range of motion exercises on the affected arm after 1 week.
- B. Assess for grasp reflex in the affected extremity.
- C. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
- D. Instruct parents to limit physical handling for 2 weeks.
Correct Answer: B
Rationale: [0, 1, 0, 0]
Assess for grasp reflex in the affected extremity is the correct answer. This action is indicated as it allows the nurse to evaluate neurological function and muscle strength in the affected arm without causing harm. Educating parents to begin range of motion exercises after 1 week (A) is contraindicated as it may exacerbate injury or delay healing. Immobilizing the arm across the abdomen (C) is also contraindicated as it can restrict movement and hinder recovery. Instructing parents to limit physical handling for 2 weeks (D) is not the best option as it may not provide the necessary assessment and treatment for the newborn's condition.
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
- A. Percutaneous umbilical blood sampling.
- B. Amnioinfusion.
- C. Biophysical profile (BPP).
- D. Chorionic villus sampling (CVS).
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). At 41 weeks of gestation, a positive contraction stress test indicates potential placental insufficiency. A BPP assesses fetal well-being by evaluating fetal movement, muscle tone, breathing, amniotic fluid volume, and heart rate reactivity. This test helps determine the need for immediate delivery.
Percutaneous umbilical blood sampling (A) is used to directly sample fetal blood for genetic testing and not for assessing fetal well-being. Amnioinfusion (B) is used to increase amniotic fluid volume during labor and not for evaluating fetal well-being. Chorionic villus sampling (D) is an invasive prenatal diagnostic test for genetic abnormalities and not for assessing fetal well-being.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil.
- B. Popliteal angle of 90°.
- C. Creases over the entire foot sole.
- D. Raised areolas with 3 to 4 mm buds.
Correct Answer: A
Rationale: The correct answer is A: Minimal arm recoil. In preterm infants, particularly those born at 26 weeks of gestation, minimal arm recoil is expected due to underdeveloped muscle tone. This is a characteristic finding in the New Ballard Score assessment for preterm newborns. Option B, popliteal angle of 90°, is incorrect as preterm infants typically have a popliteal angle greater than 90°. Option C, creases over the entire foot sole, is also incorrect as preterm infants usually have a smooth foot sole without creases. Option D, raised areolas with 3 to 4 mm buds, is not relevant to the assessment of gestational age in preterm newborns.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my protein intake to 60 grams each day.
- B. I should drink 2 liters of water each day.
- C. I should increase my overall daily caloric intake by 300 calories.
- D. I should take 600 micrograms of folic acid each day.
Correct Answer: D
Rationale: The correct answer is D because folic acid is crucial during pregnancy to prevent birth defects like spina bifida. It is recommended to take 600 micrograms daily. Choice A is incorrect as the recommended protein intake is 71 grams/day. Choice B is important but doesn't address nutrition specifically. Choice C is unnecessary and could lead to excessive weight gain.
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Contractions lasting 80 seconds.
- B. Early decelerations in the PHR.
- C. Temperature 37.4° C (99 3* F).
- D. PHR baseline 170/min.
Correct Answer: D
Rationale: The correct answer is D: PHR baseline 170/min. A baseline fetal heart rate (FHR) of 170/min is considered tachycardia in labor, which may indicate fetal distress. The nurse should report this finding to the provider promptly for further evaluation and intervention. Contractions lasting 80 seconds (choice A) are within the normal range. Early decelerations (choice B) are typically benign and do not require immediate intervention. A temperature of 37.4° C (choice C) is slightly elevated but not a critical finding in active labor. Therefore, choice D is the most concerning and requires immediate attention.