Nokea
After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?
- A. Yogurt.
- B. Whole milk.
- C. Collard greens.
- D. Strawberries.
Correct Answer: D
Rationale: Strawberries are a good source of folic acid, suitable for the client's dietary restrictions, unlike yogurt, milk, or collard greens, which either lack folic acid or are disliked.
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A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?
- A. Document the finding in the medical record.
- B. Schedule the client for a biophysical profile.
- C. Request another nurse measure the fundus.
- D. Notify the healthcare provider of the finding.
Correct Answer: B
Rationale: A fundal height of 29 cm at 26 weeks in a twin pregnancy is discrepant and may indicate issues like growth restriction or polyhydramnios, necessitating a biophysical profile to assess fetal well-being.
History and Physical:
Nurses' Notes
Flow Sheet
The client is a 26-year-old female gravida 2, para 1, term 1, living 1. She was admitted to the labor and delivery unit with cervical dilation of 4 cm, 70% effacement, and -1 station. Her pregnancy has been uncomplicated, and she has no significant medical history.
A nurse is caring for a 26-year-old female client in the labor and delivery unit. The client is gravida 2, para 1, term 1, living 1, and is admitted with cervical dilation of 4 cm, 70% effacement, and -1 station. The pregnancy has been uncomplicated.
The nurse reviews the client data. Drag the word choices to complete the sentence. Abnormal FHR patterns can result in [Dropdown Group 1], [Dropdown Group 2], and [Dropdown Group 3].
- A. Acidemia.
- B. Hypoxemia.
- C. Hypoxia.
- D. Meconium stool.
- E. Maternal hypotension.
- F. Hypoglycemia.
Correct Answer: A,B,C
Rationale: Abnormal FHR patterns indicate acidemia (low pH), hypoxemia (low blood oxygen), and hypoxia (tissue oxygen deficiency), directly affecting fetal oxygenation.
A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?
- A. Encourage breastfeeding every 2 to 3 hours.
- B. Give zidovudine 6 to 12 hours after birth.
- C. Administer antibiotics for 7 to 10 days.
- D. Delay the initial bath for 1 to 2 days.
Correct Answer: B
Rationale: Zidovudine within 6-12 hours reduces HIV transmission risk in newborns of HIV-positive mothers, unlike breastfeeding, which is contraindicated, or antibiotics and delayed bathing, which are irrelevant.
The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?
- A. Shallow and irregular respirations.
- B. Flaring of the nares.
- C. Abdominal breathing with synchronous chest movement.
- D. Respiratory rate of 50 breaths per minute.
Correct Answer: B
Rationale: Nasal flaring indicates increased breathing effort, a sign of respiratory distress in newborns, unlike normal respiratory patterns.
A client receiving a solution of magnesium sulfate suddenly develops right upper quadrant pain. After reviewing abnormal laboratory results, what action should the nurse implement? (Select all that apply)
- A. Evaluate fetal heart rate and contraction patterns.
- B. Obtain prescription to repeat hepatic panel.
- C. Monitor for evidence of seizure activity.
- D. Check the urinary output in hourly urinometer.
- E. Inspect the perineum for vaginal bleeding.
Correct Answer: A,B,C,D
Rationale: Monitoring fetal heart rate, repeating hepatic panel, checking for seizures, and assessing urinary output address potential HELLP syndrome and renal function in preeclampsia.