Nokea
A nurse is collecting data from a client who has hyperemesis gravidarum.
Which of the following findings should the nurse anticipate?
- A. Increased fundal height
- B. Poor skin turgor
- C. Decreased pulse rate
- D. Proteinuria
Correct Answer: B
Rationale: Poor skin turgor is a common finding in clients with hyperemesis gravidarum due to dehydration. Excessive vomiting leads to fluid loss and dehydration, resulting in poor skin elasticity and turgor.
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A nurse is reinforcing teaching with a client about common discomforts during the first trimester of pregnancy. Which of the following discomforts should the nurse include in the teaching?
- A. Urination urgency and frequency
- B. Tingling in the fingers
- C. Round ligament pain
- D. Perineal discomfort and pressure
Correct Answer: A
Rationale: Increased urgency and frequency of urination are common discomforts during the first trimester of pregnancy. This occurs due to hormonal changes and the growing uterus pressing on the bladder, which reduces its capacity.
A nurse is reinforcing teaching about breastfeeding with a client who is postpartum.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will nurse my baby for 5 to 10 minutes on each breast.
- B. I will make sure that just the nipple is in my baby's mouth.
- C. I will apply vitamin E oil to my nipples after each feeding.
- D. I will lay my baby on a pillow at the level of my breast.
Correct Answer: D
Rationale: Using a pillow to support the baby at breast level ensures proper positioning and latch, making breastfeeding more comfortable and effective, indicating understanding of the teaching.
A nurse in a prenatal clinic is reinforcing teaching with a client who is at 20 weeks of gestation and has a low calcium level.
Which of the following foods should the nurse recommend the client increase in her diet?
- A. Peanut butter
- B. Avocados
- C. Yogurt
- D. Long-grain rice
Correct Answer: C
Rationale: Yogurt is an excellent calcium source, vital for fetal bone development and maternal health, making it the best recommendation for low calcium levels.
A nurse is reinforcing discharge instructions about breastfeeding with a client. Which of the following statements should the nurse make?
- A. You should recognize that your baby sucking on his hands is a hunger cue.
- B. You should feed your baby for 10 minutes on each breast.
- C. You should feed your baby six times a day.
- D. You should wake your baby at least every 6 hours at night for feedings.
Correct Answer: A
Rationale: Recognizing that sucking on hands is a hunger cue helps ensure timely feeding, supporting a successful breastfeeding routine and adequate nutrition for the baby.
A nurse is reinforcing teaching about preventing mastitis with a client who is breastfeeding.
Which of the following instructions should the nurse include?
- A. Wear an underwire bra between feedings.
- B. You should use a breast pump if you plan to return to work.
- C. Wash your nipples with soap and water daily.
- D. Cover your breasts immediately after feedings.
Correct Answer: B
Rationale: Using a breast pump prevents engorgement when returning to work, reducing mastitis risk by maintaining milk flow and supply.