Nokea
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.
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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.
Which patient would require additional calories and nutrients?
- A. A 36-year-old female gravida 2, para 1, in her first trimester of pregnancy
- B. An 18-year-old female who delivered a 7-lb baby and is bottle feeding
- C. A 23-year-old female who had a cesarean birth and is bottle feeding
- D. A 20-year-old female who had a vaginal birth 5 months ago and is breastfeeding
Correct Answer: D
Rationale: The correct answer is D because breastfeeding requires additional calories and nutrients to support the mother's milk production and maintain her own health. Breastfeeding burns extra calories, so the mother needs to consume more to meet her body's needs. Additionally, breastfeeding mothers need to ensure they are getting enough nutrients like calcium, iron, and protein to support their own health and the production of nutritious breast milk for their baby.
Choice A is incorrect because the patient is in her first trimester of pregnancy, not breastfeeding. Choice B is incorrect because bottle feeding does not require as many additional calories and nutrients as breastfeeding. Choice C is incorrect because although the patient had a cesarean birth, the method of feeding (bottle feeding) does not require as much additional nutrition as breastfeeding.
A pregnant patient's diet may not meet her need for folate. Which food choice is an excellent source of this nutrient?
- A. Chicken
- B. Cheese
- C. Potatoes
- D. Green leafy vegetables
Correct Answer: D
Rationale: The correct answer is D: Green leafy vegetables. Green leafy vegetables such as spinach, kale, and broccoli are excellent sources of folate, a crucial nutrient for pregnant women to prevent neural tube defects in the fetus. These vegetables are rich in natural folate, making them an ideal choice for meeting the increased folate requirements during pregnancy. Chicken (A), cheese (B), and potatoes (C) do not contain as high levels of folate as green leafy vegetables, making them less optimal choices for ensuring adequate intake of this essential nutrient during pregnancy.
The nurse states to the newly pregnant patient, 'Tell me how you feel about being pregnant.' Which communication technique is the nurse using with this patient?
- A. Clarifying
- B. Paraphrasing
- C. Reflection
- D. Structuring
Correct Answer: A
Rationale: The nurse is attempting to follow up and check the accuracy of the patient's message, which is clarifying.
When performing daily head to toe assessment of a 1-day old newborn the nurse observes yellow tint to the skin on the forehead, sternum, and abdomen. What action should the nurse take?
- A. Measure bilirubin levels using transcutaneous bilirubinometer
- B. Review maternal medical records for blood type and Rh factor
- C. Prepare the newborn for phototherapy
- D. Evaluate cord results
Correct Answer: A
Rationale: Measuring bilirubin levels (A) is the first step to determine if phototherapy is necessary for jaundice.