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When assessing the fruit intake of a pregnant client, the nurse notes that the client usually eats 1 piece of fruit per day and drinks a 12 oz glass of fruit juice per day. Which of the following is the most important communication for the nurse to make?
- A. You are effectively meeting your daily fruit requirements.
- B. Fruit juices are excellent sources of folic acid.
- C. It would be even better if you were to consume more whole fruits and less fruit juice.
- D. Your fruit intake far exceeds the recommended daily fruit intake.
Correct Answer: C
Rationale: Whole fruits provide fiber and additional nutrients compared to fruit juices, which may contain added sugars. Encouraging increased consumption of whole fruits aligns with healthy dietary guidelines for pregnancy.
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What alternative could the nurse suggest to someone practicing pica?
- A. Replace laundry starch with salt
- B. Replace ice with frozen fruit juice
- C. Replace soap with cream cheese
- D. Replace soil with uncooked pie crust
Correct Answer: B
Rationale: Replacing ice with frozen fruit juice provides a safer alternative while satisfying the craving for cold substances.
A nurse is preparing a laboring person for an epidural. What is the most important nursing action prior to the procedure?
- A. ensure the birthing person is in a sitting position
- B. check for allergies to anesthesia
- C. ensure informed consent is obtained
- D. administer IV fluids
Correct Answer: C
Rationale: The correct answer is C: ensure informed consent is obtained. Prior to any medical procedure, including epidural administration, it is crucial to obtain informed consent from the patient. This involves explaining the procedure, risks, benefits, and alternatives to the patient, ensuring they understand and voluntarily agree to the procedure. Without informed consent, the procedure cannot proceed ethically.
Choice A (ensure the birthing person is in a sitting position) is not the most important action as the position can be adjusted during the procedure. Choice B (check for allergies to anesthesia) is important but obtaining informed consent takes precedence. Choice D (administer IV fluids) is not a priority before obtaining informed consent.
A nurse is caring for a postpartum person with a diagnosis of uterine atony. What is the most appropriate first action to take?
- A. perform fundal massage
- B. administer a uterotonic medication
- C. perform a vaginal exam
- D. monitor vital signs
Correct Answer: A
Rationale: The correct first action is to perform fundal massage. This helps stimulate uterine contractions, which can help control bleeding due to uterine atony. The massage should be done gently but firmly to prevent further complications. Administering uterotonic medication (choice B) can be done after fundal massage. Performing a vaginal exam (choice C) can increase the risk of infection and should be avoided initially. Monitoring vital signs (choice D) is important but addressing the uterine atony should be the priority to prevent further complications.
The nurse is reviewing the procedure for alpha-fetoprotein (AFP) screening with a patient at 16 weeks’ gestation. What sample will be collected for the initial screening process?
- A. Urine
- B. Blood
- C. Saliva
- D. Amniotic fluid
Correct Answer: B
Rationale: AFP screening is done using a blood sample, which is less invasive than an amniocentesis.
Which of the following is the most appropriate nursing action for a patient who has been administered an epidural block and is now experiencing hypotension?
- A. Administer a bolus of IV fluids
- B. Place the patient in a Trendelenburg position
- C. Administer oxygen via mask
- D. Raise the head of the bed slightly
Correct Answer: A
Rationale: The correct answer is A: Administer a bolus of IV fluids. Hypotension after an epidural block is often due to vasodilation caused by the block. Administering IV fluids can help increase blood volume and improve blood pressure. This action is crucial in maintaining perfusion to vital organs.
Choice B: Placing the patient in a Trendelenburg position can potentially worsen hypotension by increasing venous return to the heart, leading to further vasodilation and reduced blood pressure.
Choice C: Administering oxygen via mask may be important in some situations but is not the primary intervention for hypotension caused by epidural block.
Choice D: Raising the head of the bed slightly is not the best option for treating hypotension as it does not address the underlying cause of vasodilation and decreased blood pressure.