Nokea
Which clients are most likely to be identified as being at high risk for pregnancy complications? Select all that apply.
- A. A client who is pregnant for the fifth time
- B. A client who is 16 years old
- C. A client who has a history of twins in the family
- D. A client who has primary hypertensive disease
- E. A client who works 40 hours a week in a factory
- F. A client who reports spotting in the first trimester
Correct Answer: A,B,D,F
Rationale: Multiple pregnancies, young age, hypertension, and spotting increase complication risks; twins or work hours are less significant.
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The nurse encourages which activity to reduce stress during pregnancy?
- A. Prenatal yoga
- B. Excessive work hours
- C. Skipping meals
- D. Caffeine consumption
Correct Answer: A
Rationale: Prenatal yoga promotes relaxation and reduces stress, supporting maternal mental health during pregnancy.
When the client asks why folic acid is important, which response by the nurse is most accurate?
- A. Folic acid helps prevent neural tube defects such as spina bifida.
- B. Folic acid helps build strong bones for your baby.
- C. Folic acid helps your baby become resistant to infections.
- D. Folic acid prevents your baby from becoming anemic.
Correct Answer: A
Rationale: Folic acid is critical for preventing neural tube defects like spina bifida by supporting early fetal development.
The nurse asks the 12-hour postpartum client, who is breastfeeding her baby now, why she has not yet received a dinner tray. The client states that her mother is bringing curry and that she won’t be eating the hospital food tonight. Which response by the nurse is best?
- A. “Please let me know if you change your mind. I can order food for you later.”
- B. “Since you are breastfeeding, you should avoid eating highly spiced food.”
- C. “I will ask the dietitian to meet with you so you can discuss your nutritional needs.”
- D. “You should not be eating highly spiced food 12 hours after delivery.”
Correct Answer: A
Rationale: Offering to order food later if the client changes her mind is the best response. Many clients have culturally based beliefs about food and beverages that should be consumed in the postpartum period. Unless contraindicated, nurses should support and encourage women to incorporate food preferences with cultural significance into their postpartum diet. Some breastfeeding infants are sensitive to certain flavors, seasonings, or foods, but, there is no evidence to support maternal food restrictions unless the infant shows a sensitivity. If there is a strong family history of a food allergy that causes anaphylaxis, such as a peanut allergy, these foods may be avoided. Many women would benefit from speaking to a dietician, but this client is not at any increased risk that would make a dietary consultation necessary. There are no food restrictions 12 hours after delivery unless there have been complications.
The nurse correctly informs the participants that women who smoke during pregnancy have a greater risk of which problem?
- A. Having a premature delivery
- B. Having a cesarean birth
- C. Having a large, overweight baby
- D. Developing a prenatal infection
Correct Answer: A
Rationale: Smoking during pregnancy increases the risk of premature delivery due to reduced oxygen and nutrient delivery to the fetus.
The nurse is preparing to administer 2 mg hydromorphone hydrochloride to the client who is 28 hours post—cesarean section. The medication available is in a concentration of 4 mg/mL. How many milliliters should the nurse administer?
- A. 0.5 mL
- B. 1.0 mL
- C. 2.0 mL
- D. 4.0 mL
Correct Answer: 0.5 mL
Rationale: (2 mg / 4 mg) x 1 mL = 0.5 mL. The nurse should administer 0.5 mL hydromorphone hydrochloride (Dilaudid).