In providing prenatal care to a pregnant patient, what does the nurse teach the expectant mother?
- A. Calcium intake is especially important in the first trimester.
- B. Protein intake needs to decrease to preserve kidney function.
- C. Folic acid is needed to help prevent birth defects and anemia.
- D. Extra vitamins and minerals should be taken as much as possible.
Correct Answer: C
Rationale: The correct answer is C because folic acid is crucial in preventing neural tube defects and anemia in the developing fetus. The nurse should teach the expectant mother about the importance of taking folic acid supplements before and during pregnancy. Folic acid is essential for proper cell division and growth, reducing the risk of birth defects.
Choice A is incorrect because calcium intake is important throughout pregnancy, not just in the first trimester. Choice B is incorrect as protein intake should be adequate to support maternal and fetal growth, not decreased. Choice D is incorrect as excessive intake of vitamins and minerals can be harmful to the mother and the baby.
In summary, the expectant mother should be educated on the importance of folic acid supplementation to prevent birth defects and anemia, while also ensuring a balanced diet with all essential nutrients.
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The rate of obesity in the United States has reached epidemic proportions. Morbidity and mortality for both the mother and baby are increased in these circumstances. The nurse caring for the patient with an elevated BMI should be cognizant of these potential complications and plan care accordingly. Significant risks include (Select all that apply.)
- A. Breech presentation
- B. Ectopic pregnancy
- C. Birth defects
- D. Venous thromboembolism
Correct Answer: A
Rationale: The correct answer is A: Breech presentation. Obesity can lead to a larger fetus, increasing the risk of breech presentation. The rationale is that excess fat can hinder the baby's ability to turn head down. Other choices are incorrect because: B: Ectopic pregnancy is not related to obesity, C: Birth defects can be influenced by maternal health but are not directly linked to obesity, and D: Venous thromboembolism is more associated with immobility and hypercoagulable states rather than obesity.
A patients decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patients health problem?
- A. Antigens have bound to antibodies and formed inappropriate immune complexes.
- B. The patients body has mistakenly identified a normal constituent of the body as foreign.
- C. Sensitized T cells have caused cell and tissue damage.
- D. Mast cells have released histamines that directly cause cell lysis.
Correct Answer: B
Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction.
Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.
A patient, diagnosed with cancer of the lung, has just been told he has metastases to the brain. What change in health status would the nurse attribute to the patients metastatic brain disease?
- A. Chronic pain
- B. Respiratory distress
- C. Fixed pupils
- D. Personality changes
Correct Answer: D
Rationale: The correct answer is D: Personality changes. Metastases to the brain can affect cognitive function and behavior, leading to personality changes. This is due to the impact on specific areas of the brain responsible for personality and behavior. Chronic pain (A) is more commonly associated with advanced cancer and not specific to brain metastases. Respiratory distress (B) is more likely related to lung cancer itself, not brain metastases. Fixed pupils (C) may indicate brainstem involvement, but personality changes are a more direct and common manifestation of brain metastases.
A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the patients diagnosis will be?
- A. Ossiculitis
- B. Mnires disease
- C. Ototoxicity
- D. Labyrinthitis
Correct Answer: D
Rationale: The correct answer is D: Labyrinthitis. This condition presents with sudden onset vertigo, nausea, vomiting, tinnitus, and hearing loss, which are all symptoms described by the patient. Labyrinthitis is commonly caused by a viral infection affecting the inner ear, leading to inflammation of the labyrinth. This inflammation disrupts the balance and hearing functions of the inner ear, resulting in the symptoms mentioned.
A: Ossiculitis involves inflammation of the middle ear bones, typically causing conductive hearing loss, not the sudden onset of vertigo and other symptoms described.
B: Mnire's disease is characterized by recurrent episodes of vertigo, tinnitus, and hearing loss, but it typically does not present with sudden onset incapacitating vertigo.
C: Ototoxicity is caused by exposure to certain medications or chemicals that damage the inner ear structures, leading to hearing loss. While hearing loss is a symptom, the sudden onset of vertigo is not typically associated with ototoxicity.
A nurse is checking orders. Which order shouldthe nurse question?
- A. A normal saline enema to be repeated every 4 hours until stool is produced
- B. A hypertonic solution enema for a patient with fluid volume excess
- C. A Kayexalate enema for a patient with severe hypokalemia
- D. An oil retention enema for a patient with constipation
Correct Answer: B
Rationale: The correct answer is B because giving a hypertonic solution enema to a patient with fluid volume excess can worsen the condition by drawing more fluid into the colon. This can lead to further fluid volume overload and electrolyte imbalances. The other choices are incorrect because:
A: Normal saline enema is appropriate for constipation.
C: Kayexalate enema is used to treat hyperkalemia, not hypokalemia.
D: Oil retention enema is indicated for constipation to soften stool.