Nokea
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.
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- 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.
A 33-year-old client at 9 weeks gestation tells the nurse that while she has 'cut down,' she still has at least one alcoholic drink every evening before bedtime. What intervention should the nurse implement?
- A. Notify child protective services of the client's illicit drug use and probable child endangerment
- B. Praise the client for her actions and offer to discuss ways to decrease consumption even more
- C. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit
- D. Discuss the risks of alcohol use and encourage complete abstinence
Correct Answer: D
Rationale: Complete abstinence (D) is recommended to prevent fetal alcohol spectrum disorders.
A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?
- A. Raise the foot of the bed
- B. Assess for vaginal bleeding
- C. Evaluate the fetal heart rate
- D. Take the client's blood pressure
Correct Answer: A
Rationale: These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed (A) will increase venous return and provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring that the silent is in a lateral position are also appropriate interventions.
A pregnant patient would like to know which foods, other than dairy products, contain the most calcium. Which food group would the nurse recommend?
- A. Legumes
- B. Lean meat
- C. Whole grains
- D. Yellow vegetables
Correct Answer: A
Rationale: The correct answer is A: Legumes. Legumes such as chickpeas, lentils, and beans are rich sources of calcium. They provide a plant-based alternative for calcium intake. Legumes are also high in fiber, protein, and other essential nutrients beneficial for pregnancy. Lean meat (B) and yellow vegetables (D) are not significant sources of calcium. While whole grains (C) offer some calcium, they are not as high in calcium content as legumes. Therefore, for a pregnant patient looking to increase calcium intake without relying on dairy products, legumes are the most recommended food group.
The nurse's assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first?
- A. Position radiant warmer over the crib
- B. Assess the infants blood glucose level
- C. Nipple feed 1 ounce 1% glucose in water
- D. Place the infant in side-lying position
Correct Answer: A
Rationale: A radiant warmer (A) helps stabilize the infant's temperature and provides immediate warmth.