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A nurse is reinforcing teaching with a client who is pregnant and does not consume dairy products.
Which of the following food options should the nurse recommend as the best source of dietary calcium?
- A. 1 cup sweet white corn.
- B. 1 baked potato.
- C. 1 cup kale.
- D. 1 large banana.
Correct Answer: C
Rationale: Kale is an excellent non-dairy calcium source, providing about 177 mg per cup, ideal for meeting pregnancy calcium needs.
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Nurses' Notes: The newborn is lying in a bassinet, lightly swaddled. Jitteriness observed when disturbed, weak cry, mottled extremities, mild acrocyanosis. Respirations rapid but unlabored. No lethargy, no feedings since birth. Vital Signs: Heart rate: 156/min, Respiratory rate: 64/min, Temperature: 36.1°C (97.0°F), Oxygen saturation: 96% on room air, Blood glucose level: 30 mg/dL.
Complete the diagram by dragging from the choices below to specify: Condition, Actions to Take, Parameters to Monitor (2 Correct). Condition Choices: A. Hypoglycemia, B. Congenital heart defect, C. Neonatal sepsis, D. Neonatal abstinence syndrome. Actions: A. Obtain a capillary blood glucose reading, B. Feed the newborn immediately with breastmilk or formula, C. Administer IV glucose as prescribed, D. Initiate phototherapy, E. Place under a radiant warmer. Parameters: A. Blood glucose levels, B. Respiratory effort, C. Serum bilirubin levels, D. Skin integrity, E. Oxygen saturation.
- A. Hypoglycemia
- B. Obtain a capillary blood glucose reading
- C. Feed the newborn immediately with breastmilk or formula
- D. Blood glucose levels
- E. Respiratory effort
Correct Answer: A,A,B,A,B
Rationale: Low glucose (30 mg/dL) and jitteriness indicate hypoglycemia; feeding and glucose checks address it; glucose and respiratory effort monitor progress.
History and Physical: The client reports a history of one previous cesarean section due to breech presentation. She smokes half a pack of cigarettes daily and has a BMI greater than 30. The client denies leakage of amniotic fluid and describes positive fetal movement. Vital Signs: Temperature: 98.6°F (37°C), Pulse: 88 beats/min, Respiratory Rate: 16 breaths/min, Blood Pressure: 128/78 mmHg, Oxygen Saturation: 98% on room air. Nurses' Notes (0830 and 0845): 0830: The client is grimacing and reports discomfort. Fetal heart rate is 148 beats per minute. Fundal height measures 28 cm. 0845: Uterine contractions every 2 to 3 minutes, moderate in intensity, lasting 60 seconds.
The nurse should recommend to first address the client's ___, followed by the client's ___.
- A. Uterine contraction frequency
- B. History of cesarean delivery
Correct Answer: A,B
Rationale: Frequent contractions indicate preterm labor risk at 30 weeks; prior cesarean increases uterine rupture risk, both needing prompt attention.
A home health nurse is caring for a client who has unilateral mastitis and is experiencing discomfort in the affected breast.
Which of the following instructions should the nurse include?
- A. Recommend the client avoid wearing a nursing bra until symptoms resolve.
- B. Suggest the client apply warm compresses to the affected breast.
- C. Encourage the client to limit oral fluid intake to decrease milk production.
- D. Tell the client to apply hydrocortisone ointment to the affected area.
Correct Answer: B
Rationale: Applying warm compresses relieves pain and inflammation in mastitis, promoting circulation and healing.
A nurse is reinforcing teaching about car seat safety with a parent of a newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
- A. I can turn the car seat so it faces forward when my baby weighs 15 pounds.
- B. I will place a thick soft pad behind my baby's back.
- C. I should place my baby in the car seat at a 90-degree angle.
- D. I will place the retainer clip at the level of my baby's armpit.
Correct Answer: D
Rationale: Placing the retainer clip at the armpit level ensures proper harness positioning, distributing crash forces safely across the baby’s chest and shoulders.
A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 6 to 8 hours.
Correct Answer: A
Rationale: Early ambulation prevents blood stasis, a key measure to reduce thrombophlebitis risk post-cesarean.