Nokea
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.
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A newborn infant is receiving immunization prior discharge. Which action should the nurse implement?
- A. Give the first dose of the vaccine for rotavirus if any have diarrhea now.
- B. Obtain signed consent from the mother for administration of hepatitis B vaccine
- C. Prepare the first dose for DTaP
- D. Ask the mother if she wants the infant immunized for
Correct Answer: B
Rationale: Hepatitis B vaccine is routinely given at birth, and consent is required (B).
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.
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 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.
In order to increase the absorption of iron by a pregnant patient, which beverage should an iron preparation be given with?
- A. Tea
- B. Milk
- C. Coffee
- D. Orange juice
Correct Answer: D
Rationale: To increase iron absorption, it should be taken with Vitamin C. Orange juice is high in Vitamin C, which enhances non-heme iron absorption. Tea and coffee contain tannins that inhibit iron absorption. Milk contains calcium, which can interfere with iron absorption. Therefore, the correct choice is D as it provides the necessary Vitamin C to improve iron absorption.