Nokea
In which step of the nursing process does the nurse determine the appropriate interventions for the identified nursing diagnosis?
- A. Planning
- B. Evaluation
- C. Assessment
- D. Intervention
Correct Answer: A
Rationale: The planning phase involves determining appropriate interventions for identified problems during assessment.
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When explaining the recommended weight gain to your patient, the nurse's teaching should include which statement?
- A. All pregnant women need to gain a minimum of 25 to 35 lb.'
- B. The fetus, amniotic fluid, and placenta require 15 lb of weight gain.'
- C. Weight gain in pregnancy is based on the patient's prepregnant body mass index.'
- D. More weight should be gained in the first and second trimesters and less in the third.'
Correct Answer: C
Rationale: The correct answer is C because weight gain in pregnancy should be individualized based on the patient's prepregnant body mass index (BMI). This is important as it takes into consideration the patient's starting weight and helps to determine a healthy range of weight gain to support both maternal and fetal health. This approach is evidence-based and helps to prevent complications such as gestational diabetes and preeclampsia.
Explanation for why the other choices are incorrect:
A: This statement is incorrect because not all pregnant women need to gain the same amount of weight. Weight gain recommendations vary based on the patient's BMI.
B: This statement is incorrect as it provides a specific number for weight gain, which may not be accurate for all pregnant women. Weight gain should be individualized based on BMI.
D: This statement is incorrect because weight gain recommendations are distributed evenly across the trimesters, not necessarily more in the first and second trimesters and less in the third.
Regarding advanced roles of nursing, which statement related to clinical practice is the most accurate?
- A. Family nurse practitioners (FNPs) can assist with childbirth care in the hospital setting.
- B. Clinical nurse specialists (CNSs) provide primary care to obstetric patients.
- C. Neonatal nurse practitioners provide emergency care in the postbirth setting to high-risk infants.
- D. A certified nurse midwife (CNM) is not considered to be an advanced practice nurse.
Correct Answer: C
Rationale: Neonatal NPs provide specialized care for high-risk neonates in the birth room and NICU as needed.
The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?
- A. Between the time the temperature falls and rises
- B. Between 36 and 48 hours after the temperature rises
- C. When the temperature falls and remains low for 36 hours
- D. Within 72 hours before the temperature falls
Correct Answer: A
Rationale: In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone. Therefore, intercourse between the time of the temperature fall and rise (A) is the best time for conception.
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.
Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching on the gravid client?
- A. The client's readiness to learn
- B. The client's educational background
- C. The order in which the information is presented
- D. The extent to which the pregnancy was planned
Correct Answer: A
Rationale: When teaching any client, readiness to learn (A) is the most important criterion. For example, the client with severe morning sickness in the first trimester may not be 'ready to learn' about ways to relieve morning sickness.