Nokea
ATI Maternal Newborn
- A. Teach the patient about MyPlate.
- B. Review the patient's current dietary intake.
- C. Instruct the patient to limit the intake of fatty foods.
- D. Caution the patient to avoid large doses of vitamins, especially those that are fat-soluble.
Correct Answer: B
Rationale: The correct answer is B because reviewing the patient's current dietary intake provides crucial information on their nutrition status and helps identify any deficiencies or excesses. This step allows for personalized dietary recommendations tailored to the patient's specific needs.
A: Teaching about MyPlate is a general recommendation but does not address the individual patient's dietary requirements.
C: Instructing to limit fatty foods is a generic recommendation and may not be appropriate for every patient.
D: Cautioning against large doses of fat-soluble vitamins is important, but it is not the initial step in assessing the patient's overall dietary intake.
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A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain medication. Review of the client's record indication that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal examination reveals that the client cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement?
- A. Discontinue the Pitocin infusion
- B. Medicate the client with an additional 1 mg of Stadol IV push
- C. Notify the healthcare provider
- D. Instruct the client to use deep breathing during contraction
Correct Answer: D
Rationale: Deep breathing techniques (D) can help manage pain without additional medication.
Changes in the diet of the pregnant patient who has phenylketonuria would include
- A. adding foods high in vitamin C.
- B. eliminating drinks containing aspartame.
- C. restricting protein intake to <20 g a day.
- D. increasing caloric intake to at least 1800 cal/day.
Correct Answer: B
Rationale: The correct answer is B: eliminating drinks containing aspartame. Patients with phenylketonuria lack the enzyme to metabolize phenylalanine, found in aspartame. Avoiding aspartame-containing products is crucial to prevent phenylalanine buildup. Choice A is incorrect as vitamin C is not directly related to phenylketonuria. Choice C is incorrect as protein restriction is necessary, but the recommended intake is individualized and not a fixed amount. Choice D is incorrect as caloric intake is important, but the focus should be on managing phenylalanine levels.
A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 7 cm, 100% effaced, and the fetus is at +1 station. The client begins to push forcefully with contractions. What action should the nurse take?
- A. Encourage the client to pant-blow during contractions.
- B. Assist the client to push with contractions.
- C. Prepare for an immediate delivery.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Pant-blow breathing helps prevent premature pushing before full dilation, reducing the risk of cervical edema.
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 woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern?
- A. Edema, basilar rales, and an irregular pulse.
- B. Increased urinary output, and tachycardia.
- C. Dyspnea, bradycardia, and hypertension.
- D. Regular heart rate, and hypertension.
Correct Answer: A
Rationale: Edema, basilar rales, and an irregular pulse indicate potential cardiac decompensation, which is of greatest concern in a woman with heart disease during labor.