Nokea
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: A
Rationale: The correct answer is A because protein is essential for fetal development and increasing protein intake to 60 grams per day is recommended during pregnancy for optimal growth. Adequate protein intake helps in the formation of new tissues and cells.
Choice B is incorrect because while staying hydrated is important during pregnancy, the specific amount of 2 liters per day is not a standard recommendation and may vary depending on individual needs.
Choice C is incorrect as increasing overall daily caloric intake by 300 calories is a general guideline, not specific to the client's gestational age.
Choice D is incorrect as while folic acid is crucial during pregnancy to prevent birth defects, the recommended daily intake is usually 400-800 micrograms, so 600 micrograms is within the range but not the best answer.
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A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
- A. Feed the newborn 1 oz of water every 4 hr.
- B. Apply lotion to the newborn’s skin three times per day.
- C. Remove all clothing from the newborn except the diaper.
- D. Discontinue therapy if the newborn develops a rash.
Correct Answer: C
Rationale: Removing all clothing except the diaper ensures maximum skin exposure to the phototherapy lights, which is essential for effective treatment of hyperbilirubinemia.
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
- A. Ectopic pregnancy
- B. Hyperemesis gravidarum
- C. Incompetent cervix
- D. Postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The nurse assessed the client to be 80% effaced and 8 cm dilated, indicating she is in active labor. This client is at risk for postpartum hemorrhage, which is excessive bleeding after childbirth due to the uterus not contracting adequately to control bleeding. The risk is higher in clients who have a rapid labor progression like this client. Ectopic pregnancy (A) is not relevant in this scenario as the client is already in labor. Hyperemesis gravidarum (B) is severe nausea and vomiting during pregnancy, not related to the client's current condition. Incompetent cervix (C) is the premature dilation of the cervix, not applicable at this stage of labor.
Which stage of labor is characterized by the period between the onset of regular contractions and full cervical dilation?
- A. First stage
- B. Second stage
- C. Third stage
- D. Fourth stage
Correct Answer: A
Rationale: The correct answer is A: First stage. This stage of labor begins with the onset of regular contractions and ends with complete cervical dilation at 10 cm. During this stage, the cervix gradually thins and opens to allow the baby to pass through the birth canal. The first stage is further divided into early, active, and transition phases based on the rate of cervical dilation and effacement. The second stage (B) is characterized by the baby's descent through the birth canal and ends with the baby's delivery. The third stage (C) involves the delivery of the placenta. The fourth stage (D) is the immediate postpartum period. These stages come after the first stage of labor.
Which of the following is a potential ethical issue related to maternal request for cesarean delivery?
- A. Autonomy versus beneficence
- B. Allocation of resources
- C. Informed consent
- D. All of the above
Correct Answer: A
Rationale: The ethical issue of autonomy versus beneficence arises when a mother's request for a cesarean delivery conflicts with medical recommendations. Respecting patient autonomy while ensuring beneficence (doing what is best for the patient) can create ethical dilemmas.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. This is the correct intervention because a uterus palpable to the right above the umbilicus indicates a full bladder causing displacement of the uterus. Emptying the bladder will allow the uterus to return to the midline. Choice A is incorrect as the immediate issue is a full bladder, not requiring a wait of 2 hours. Choice B (administer simethicone) is incorrect as this medication is for gas relief and not relevant in this scenario. Choice D (instruct the client to lie on their right side) is incorrect as it does not address the underlying problem of a full bladder.