Nokea
The traditional diet of Asian women includes little meat and few dairy products and may be low in calcium and iron. The nurse can assist a patient increase her intake of these foods by which action?
- A. Suggest that she eat more tofu, bok choy, and broccoli.
- B. Suggest that she eat more hot foods during pregnancy.
- C. Emphasize the need for increased milk intake during pregnancy.
- D. Tell her husband that she must increase her intake of fruits and vegetables for the baby's sake.
Correct Answer: A
Rationale: Rationale:
A: Tofu, bok choy, and broccoli are rich sources of calcium and iron, suitable for Asian diets low in these nutrients.
B: Eating hot foods during pregnancy does not specifically address increasing intake of calcium and iron.
C: Traditional Asian diets often do not emphasize milk consumption, and not all individuals can digest milk well.
D: Fruits and vegetables are important but not specific sources of calcium and iron. Also, dietary changes should be made by the individual, not someone else.
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A patient with a BMI of 32 has a positive pregnancy test. What is the maximum number of pounds that the nurse will advise the patient gain during the pregnancy?
- A. 20 lb
- B. 25 lb
- C. 28 lb
- D. 40 lb
Correct Answer: A
Rationale: The correct answer is A (20 lb). During pregnancy, the recommended weight gain for a woman with a BMI of 30-39.9 is 11-20 pounds. This range helps reduce the risk of complications associated with excessive weight gain. Option B (25 lb) exceeds this recommended range, while options C (28 lb) and D (40 lb) are even further beyond the healthy weight gain guidelines for a BMI of 32. Thus, advising the patient to gain a maximum of 20 pounds is the most appropriate recommendation to ensure a healthy pregnancy outcome.
When should iron supplementation during a normal pregnancy begin?
- A. Before pregnancy
- B. In the first trimester
- C. In the third trimester
- D. In the second trimester
Correct Answer: D
Rationale: The correct answer is D: In the second trimester. During the second trimester, the demand for iron significantly increases due to the rapid growth of the fetus and expansion of maternal blood volume. This is the optimal time to begin iron supplementation to prevent iron deficiency anemia in both the mother and the developing baby. Starting iron supplementation in the first trimester may not be necessary as iron needs are not as high yet. Waiting until the third trimester may lead to insufficient time for iron stores to build up adequately. Beginning before pregnancy is not necessary unless the mother has pre-existing iron deficiency.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?
- A. Deep tendon reflexes 2+
- B. Blood pressure 140/90
- C. Respiratory rate 18/minute
- D. Urine output 90 ml/4 hours
Correct Answer: D
Rationale: Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.
A 33-year-old client at 9 weeks gestation tells the nurse that while she has 'cut down,' she still has at least one alcoholic drink every evening before bedtime. What intervention should the nurse implement?
- A. Notify child protective services of the client's illicit drug use and probable child endangerment
- B. Praise the client for her actions and offer to discuss ways to decrease consumption even more
- C. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit
- D. Discuss the risks of alcohol use and encourage complete abstinence
Correct Answer: D
Rationale: Complete abstinence (D) is recommended to prevent fetal alcohol spectrum disorders.
Which patient is most at risk for a low-birth-weight infant?
- A. 22-year-old, 60 inches tall, normal prepregnant weight
- B. 18-year-old, 64 inches tall, body mass index is <18.5
- C. 30-year-old, 78 inches tall, prepregnant weight is 15 lb above the norm
- D. 35-year-old, 75 inches tall, total weight gain in previous pregnancies was 33 lb
Correct Answer: B
Rationale: The correct answer is B because a low body mass index (<18.5) indicates underweight, which is a risk factor for delivering a low-birth-weight infant. Underweight individuals may have inadequate nutrition and lower reserves for a healthy pregnancy.
Choice A is less likely as the patient has a normal prepregnant weight. Choice C's prepregnant weight being above the norm suggests a healthy weight. Choice D's total weight gain in previous pregnancies being 33 lb indicates a healthy weight maintenance during pregnancy.