Nokea
Before teaching the client about the nutritional needs during pregnancy, which nursing intervention is most appropriate?
- A. Determine if the client needs to gain or lose weight.
- B. Assess the client's current eating pattern and preferences.
- C. Determine if the client knows how to accurately count calories.
- D. Develop a sample menu that includes the required nutrients.
Correct Answer: B
Rationale: Assessing the client's eating patterns and preferences provides a baseline for tailored nutritional education.
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Which laboratory test should the nurse monitor for a client with preeclampsia?
- A. Platelet count
- B. Blood glucose
- C. Cholesterol levels
- D. Thyroid function
Correct Answer: A
Rationale: Monitoring platelet count is critical in preeclampsia, as low platelets may indicate severe disease or HELLP syndrome.
Which instruction should the nurse provide about newborn feeding?
- A. Feed on a strict schedule
- B. Breastfeed or formula-feed on demand
- C. Avoid feeding at night
- D. Offer water between feedings
Correct Answer: B
Rationale: Feeding on demand supports the newborn's nutritional needs and promotes bonding and growth.
Which instruction should the nurse provide about postpartum recovery?
- A. Resume heavy exercise immediately
- B. Monitor vaginal bleeding for heavy flow
- C. Avoid bathing for two weeks
- D. Ignore perineal discomfort
Correct Answer: B
Rationale: Monitoring vaginal bleeding for heavy flow is crucial to detect postpartum hemorrhage, a key recovery instruction.
Multiple women are being seen in a clinic for various conditions. From which clients should the nurse prepare to obtain a group beta streptococcus (GBS) culture? Select all that apply.
- A. The client who is having symptoms of preterm labor
- B. The women who had a neonatal death 1 year ago
- C. All pregnant women coming to the clinic for care
- D. The women who had a spontaneous abortion 1 week ago
- E. The women who had an abortion for an unwanted pregnancy
Correct Answer: A,C
Rationale: The client in preterm labor should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. All pregnant women, regardless of risk status, should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. There is no indication that the client with a previous neonatal death is pregnant. The client would not be screened for GBS solely because of a history of spontaneous abortion. The client would not be screened for GBS solely because of an elective abortion.
The postpartum client is being discharged to home with a streptococcal puerperal infection. The client is taking antibiotics but asks the nurse what precautions she should take at home to prevent spreading the infection to her husband, newborn, and toddler. Which is the best response by the nurse?
- A. “No precautions are necessary since you are taking antibiotics.”
- B. “You should always wear a mask when caring for your newborn and toddler.”
- C. “Wash your hands before caring for your children and after toileting and perineal care.”
- D. “Your husband should provide all cares for both children until your infection is gone.”
Correct Answer: C
Rationale: The course of an endometrial infection is approximately 7 to 10 days, and thus standard precautions should be in place for that period of time even if the client has started antibiotics. Puerperal infections are not spread by droplets, and thus a mask is not necessary. Other than hand hygiene, no additional precautions need to be taken by the client in her home. The client is able to provide cares for her children, but hand washing is required before cares.