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The nurse is caring for a client with morning sickness who is 8 weeks pregnant with her first child. What should the nurse advise the client to do to manage nausea?
- A. eat an omelet for breakfast to ensure adequate protein intake
- B. eat foods served warm with moderate amounts of spices
- C. consume most of the daily fluid intake early in the day
- D. brush the teeth immediately after eating; this helps get the food taste out that may trigger nausea
Correct Answer: C
Rationale: Consuming fluids early avoids triggering nausea later. Protein-heavy meals, spicy foods, or brushing teeth post-eating may worsen nausea.
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The nurse reviews the pattern of a nonstress test performed on a pregnant client and interprets the finding as which result? (Refer to figure.)
- A. Reactive
- B. Abnormal
- C. Nonreactive
- D. Non-reassuring
Correct Answer: A
Rationale: A nonstress test assesses fetal well-being and evaluates the ability of the fetal heart to accelerate, often in association with fetal movement. Accelerations of the fetal heart rate are associated with adequate oxygenation, a healthy neural pathway, and the fetal heart's ability to respond to stimuli. A reactive test is described as at least two fetal heart rate accelerations, with or without fetal movement, occurring within a 20-minute period and peaking at least 15 beats/minute above the baseline and lasting 15 seconds from baseline to baseline. This recording (see figure) identifies a reactive nonstress test. The fetal heart rate acceleration peaks at least 15 beats/minute and lasts for at least 15 seconds in response to fetal movement. A nonreactive test is an abnormal or nonreassuring test. In a nonreactive test, the recording does not demonstrate the required characteristics of a reactive test within a 40-minute period.
A first-time parent is discussing developmental milestones with a nurse. The nurse tells the client she can reasonably expect her child to achieve which of the following by the time the child is 2 years old?
- A. is left-hand dominant
- B. clings to caregivers in new situations
- C. walks with assistance of another
- D. says several single words
Correct Answer: D
Rationale: By age 2, children typically say several single words. Hand dominance emerges later, clinging is earlier, and walking is independent by 2.
The nurse is preparing a community educational presentation. The topic is the leading causes of death for people ages 12-19. The nurse knows that which of the following should be presented?
- A. unintentional injuries
- B. cancer
- C. homicide
- D. suicide
Correct Answer: A
Rationale: Unintentional injuries, primarily motor vehicle accidents, are the leading cause of death for ages 12-19. Cancer (B), homicide (C), and suicide (D) are significant but rank lower.
The nurse teaches a preoperative client about the nasogastric (NG) tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed during the postoperative period based on which statement by the client?
- A. When my doctor says so.
- B. When I can tolerate food without vomiting.
- C. When my gastrointestinal (GI) system is healed.
- D. When my bowels begin to function again and I begin to pass gas.
Correct Answer: D
Rationale: NG tubes are discontinued when normal function returns to the GI tract. Although the surgeon determines when the NG tube will be removed, 'When my doctor says so' does not determine the effectiveness of teaching. Food would not be administered unless bowel function returns. The tube will be removed well before GI healing occurs.
The nurse is teaching health education classes to a group of expectant parents, and the topic is preventing cognitive impairment caused by congenital hypothyroidism. What should the nurse tell the parents is the most effective means of promoting early intervention?
- A. Vitamin intake
- B. Neonatal screening
- C. Adequate protein intake
- D. Limiting alcohol consumption
Correct Answer: B
Rationale: Congenital hypothyroidism is a common preventable cause of cognitive impairment. Neonatal screening is the only means of early diagnosis followed by intervention and the subsequent prevention of cognitive impairment. Newborn infants are screened for congenital hypothyroidism before discharge from the newborn nursery and before 7 days of life. Treatment is begun immediately, if necessary. Vitamin intake and adequate protein will not specifically prevent this disorder. Alcohol consumption during pregnancy needs to be restricted rather than just limited.