Nokea
A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important is most important for the nurse to provide this client?
- A. Elevate lower legs while resting
- B. Increase caloric intake by 200 to 300 calories per day
- C. Increase water intake to 8 full glasses per day
- D. Take prescribed multivitamin and mineral supplements
Correct Answer: D
Rationale: A client who has had a spontaneous abortion or stillbirth in the last 1.5 years should take multivitamin and mineral supplements (D) and maintain a balanced diet because the previous pregnancy may have left her nutritionally depleted.
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Expectant parents ask a prenatal nurse educator, 'Which setting for childbirth limits the amount of parent-infant interaction?'
- A. Birth center
- B. Home birth
- C. Traditional hospital birth
- D. Labor, birth, and recovery room
Correct Answer: C
Rationale: In traditional hospital settings, the mother may see the infant for only short feeding periods, and the infant is cared for in a separate nursery.
A client at 32-weeks gestation is admitted to the labor and delivery unit with complaints of severe headache, visual disturbances, and epigastric pain. The client's blood pressure is 150/100 mm Hg. What condition should the nurse suspect?
- A. Gestational hypertension.
- B. Preeclampsia.
- C. Eclampsia.
- D. Chronic hypertension.
Correct Answer: B
Rationale: Preeclampsia is characterized by hypertension, proteinuria, and symptoms such as headache, visual disturbances, and epigastric pain.
The nurse is writing an expected outcome for the nursing diagnosis—acute pain related to tissue trauma, secondary to vaginal birth, as evidenced by patient stating pain of 8 on a scale of 10. Which expected outcome is correctly stated for this problem?
- A. Patient will state that pain is a 2 on a scale of 10.
- B. Patient will have a reduction in pain after administration of the prescribed analgesic.
- C. Patient will state an absence of pain 1 hour after administration of the prescribed analgesic.
- D. Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of the prescribed analgesic.
Correct Answer: D
Rationale: The outcome should be patient-centered, measurable, realistic, and attainable within a specified timeframe.
A client at 38-weeks gestation is admitted to the labor and delivery unit with mild contractions every 5 minutes. The client's cervix is dilated 2 cm, 50% effaced, and the fetus is at 0 station. The client's membranes rupture spontaneously, and the fluid is clear. What action should the nurse take next?
- A. Monitor the fetal heart rate pattern.
- B. Perform a vaginal examination.
- C. Encourage the client to ambulate.
- D. Administer pain medication.
Correct Answer: A
Rationale: Monitoring the fetal heart rate pattern after membrane rupture is essential to detect any changes in fetal status.
For the pregnant patient who is a vegan, what combination of foods will the nurse advise to meet the nutritional needs for all essential amino acids?
- A. Eggs and beans
- B. Fruits and vegetables
- C. Grains and legumes
- D. Vitamin and mineral supplements
Correct Answer: C
Rationale: The correct answer is C (Grains and legumes) because when combined, they provide all essential amino acids needed for a vegan pregnant patient. Grains are low in lysine but high in methionine, while legumes are high in lysine but low in methionine. By consuming both, the patient can achieve a complete protein profile. Choice A (Eggs and beans) is incorrect as vegans do not consume eggs. Choice B (Fruits and vegetables) lacks adequate protein and essential amino acids. Choice D (Vitamin and mineral supplements) is important for overall health but does not provide the necessary amino acids.