Nokea
Client just learned she is pregnant
The nurse should reinforce with the client to call her provider if she experiences which of the following manifestations?
- A. Decreased energy
- B. Mood swings
- C. Urinary frequency
- D. Facial edema
Correct Answer: D
Rationale: The correct answer is D: Facial edema. This manifestation can indicate a serious condition like kidney or heart failure, requiring immediate medical attention. Decreased energy (A) and mood swings (B) are common in pregnancy and usually not urgent. Urinary frequency (C) is common in pregnancy as well, but not a cause for immediate concern. Therefore, the nurse should prioritize educating the client to call her provider if she experiences facial edema to ensure prompt evaluation and treatment.
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Client at 28 weeks of gestation, history of one elective abortion at 9 weeks, birth of twins at 36 weeks, spontaneous abortion at 15 weeks
According to the GTPAL system, which of the following describes her present parity?
- A. 4-0-0-2-2
- B. 4-2-0-2-2
- C. 4-0-2-2-2
- D. 4-0-1-2-2
Correct Answer: D
Rationale: According to the GTPAL system, "G" represents the total number of pregnancies. In this case, the correct answer is D (4-0-1-2-2) because it indicates the woman has had 4 pregnancies, 0 term births, 1 preterm birth, 2 living children, and 2 abortions/miscarriages. This is the correct interpretation of her present parity. Choices A, B, and C have incorrect numbers for preterm births, living children, or abortions/miscarriages, making them incorrect.
Client is a physical trainer, weighs 220 lb, requires an increase of protein by 20 g/kg/day, has taken 0.8 g of protein/kg/day in the past
How much total protein/day should the nurse recommend? Be sure to enter the number AND the unit of measurement (g).
Correct Answer: 2200 g
Rationale: The correct answer is 2200 g/day. This meets the recommended daily protein intake for an average adult, which is around 0.8 g/kg of body weight. For a 70 kg adult, this would be 56 g of protein per meal, totaling 168 g/day. Adding a margin for increased protein needs in certain conditions, such as illness or intense physical activity, brings the total to around 2200 g/day. Other choices are incorrect because they do not meet the recommended daily protein intake for adults and may lead to deficiencies or excess intake.
Client at 34 weeks of gestation, suspected placenta previa
Which of the following actions should the nurse take?
- A. Perform a rectal exam.
- B. Apply an external fetal monitor.
- C. Complete a vaginal exam.
- D. Apply ice to the perineal area.
Correct Answer: B
Rationale: The correct answer is B: Apply an external fetal monitor. This action is crucial in monitoring the fetal heart rate and uterine contractions during labor, ensuring the well-being of both the mother and the baby. Performing a rectal exam (choice A) is not indicated in this context. Completing a vaginal exam (choice C) may be necessary but is not the immediate priority. Applying ice to the perineal area (choice D) is not relevant for fetal monitoring. Other choices are not provided.
Client pregnant, taking iron supplements for iron-deficiency anemia, reports black stools, no abdominal pain or cramping
Which of the following responses by the nurse is appropriate?
- A. What else have you been eating?
- B. Go to the emergency room and your provider will meet you there.
- C. This is expected because of the way iron is broken down during digestion.
- D. Come to the office and we will check things out.
Correct Answer: C
Rationale: The correct answer is C because it provides an appropriate explanation for the situation. Iron is known to cause dark stools due to its breakdown in the digestive system. This response shows understanding and reassures the patient. Choice A is relevant but doesn't address the specific issue. Choice B is inappropriate as it suggests an unnecessary visit to the emergency room. Choice D is a general invitation without addressing the concern.
Client might have a hydatidiform mole
The nurse should monitor the client for which of the following findings?
- A. Whitish vaginal discharge
- B. Fetal heart rate irregularities
- C. Excessive uterine enlargement
- D. Rapidly dropping human chorionic gonadotropin (hCG) levels
Correct Answer: C
Rationale: The correct answer is C: Excessive uterine enlargement. This finding is important to monitor in a pregnant client as it may indicate conditions such as multiple gestation, hydramnios, or molar pregnancy, which could pose risks to both the mother and baby. Monitoring uterine size helps in assessing fetal growth and development. Whitish vaginal discharge (A) could be a normal finding or indicate a yeast infection, while fetal heart rate irregularities (B) would be monitored using fetal monitoring, not uterine size. Rapidly dropping hCG levels (D) could suggest a miscarriage or ectopic pregnancy, but it is not directly related to uterine enlargement.