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The client, who is Chinese American and pregnant, is receiving nutritional counseling about the need for increased amounts of calcium in her diet. Which response by the nurse is most helpful when the client states she does not consume any dairy products?
- A. “Tell me how you perceive dairy products in your culture.”
- B. “Try having a glass of soy milk at each meal and at bedtime.”
- C. “Tell me about your intake of fortified tofu and leafy green vegetables.”
- D. “Rice milk fortified with calcium and nettle tea are good calcium choices.”
Correct Answer: C
Rationale: Assessing the client’s intake of calcium-rich foods is the best response. Both fortified tofu and leafy green vegetables are high in calcium and are common foods consumed in the Chinese American diet. Although asking about the client’s perception of dairy products shows cultural sensitivity, the client has already stated she does not consume these. This statement is not the most helpful regarding helping the client to increase calcium intake in her diet. The nurse is making a recommendation without further assessing the client’s dietary preferences. Soy milk should be calcium fortified; yet, according to research the calcium content can be as much as 85 percent less than the amount indicated on the product label. Both rice milk fortified with calcium and nettle tea are sources of calcium; however, the nurse is making an assumption that the client consumes these beverages.
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The pregnant client presents to the ED with a large amount of painless, bright red bleeding. She looks to be about 30 to 34 weeks pregnant based on her uterine size. She speaks limited English and is unable to communicate with the staff. Which actions should the nurse take? Select all that apply.
- A. Call for an interpreter for this client.
- B. Establish an intravenous access.
- C. Auscultate for fetal heart tones.
- D. Place the client into a lithotomy position.
- E. Perform a digital pelvic examination.
Correct Answer: A,B,C
Rationale: The nurse should call for an interpreter so that the client is able to communicate. An IV access should be performed by the nurse to administer any needed medications. Auscultating FHT will provide information about fetal well-being. Positioning the client in a lithotomy position can cause abdominal pain, and there is no indication that birth is imminent. The pregnant client who presents in later pregnancy should never have a digital pelvic examination because this could cause additional bleeding, especially if she has placenta previa.
Which response by the nurse addresses the client's anxiety about childbirth?
- A. Your anxiety is normal, and we can discuss coping strategies like breathing exercises.
- B. You should not be anxious; childbirth is a natural process.
- C. Anxiety will harm your baby, so you need medication.
- D. Ignore your anxiety; it will go away after delivery.
Correct Answer: A
Rationale: Acknowledging anxiety as normal and offering coping strategies like breathing exercises supports the client emotionally.
Which information about shortness of breath during pregnancy is correct?
- A. It is not common during pregnancy and may indicate a blood clot in the lungs.
- B. It is probably the result of anxiety about the baby's impending delivery.
- C. It is probably caused by the enlarged uterus pressing against the diaphragm.
- D. It is probably caused by decreased oxygen secondary to slow venous circulation.
Correct Answer: C
Rationale: Shortness of breath is common in late pregnancy due to the enlarged uterus pressing against the diaphragm, limiting lung expansion.
The nurse is teaching the Muslim client how to correctly latch her baby to her breast for breastfeeding. Two student nurses are observing the instruction. Later, the client requests that the nurse not be allowed to provide her postpartum care. What most likely caused the client to be uncomfortable with the nurse?
- A. Muslim women do not want to breastfeed while in the hospital.
- B. Muslim women wait for their milk to come in before they breastfeed.
- C. Muslim women are uncomfortable breastfeeding in public situations.
- D. Muslim women only breastfeed after the infant is given boiled water.
Correct Answer: C
Rationale: Korean mothers resist breastfeeding in the hospital. Some Asian women believe colostrum is “bad,” and therefore they do not feed until actual breast milk is present. Most Muslim women breastfeed because the Koran encourages it; however, they are uncomfortable about breastfeeding in public situations and prefer privacy. Having two students observing the feeding process most likely would make the client uncomfortable, as she would desire more privacy. Some Asian cultures believe the newborn must be given boiled water until the milk is actually present.
The 22-year-old client, who is experiencing vaginal bleeding in the first trimester of pregnancy, fears that she has lost her baby at 8 weeks. Which definitive test result should indicate to the nurse that the client’s fetus has been lost?
- A. Falling beta human chorionic gonadotropin (BHCG) measurement
- B. Low progesterone measurement
- C. Ultrasound showing a lack of fetal cardiac activity
- D. Ultrasound determining crown-rump length
Correct Answer: C
Rationale: Ultrasound is used to determine if the fetus has died. The lack of fetal heart activity in a pregnancy over 6 weeks determines a fetal loss. Falling BHCG levels do not conclusively diagnose fetal demise. Low progesterone levels do not conclusively diagnose fetal demise. Crown-rump length determines only the fetal gestational age.