Which pregnant client should the nurse encourage to undergo hepatitis B testing?
- A. A client with a history of cigarette smoking
- B. A client who is a health care worker
- C. A client who emigrated in the past year from Haiti
- D. A client who was recently exposed to Haemophilus influenzae
Correct Answer: C
Rationale: Clients from high-prevalence areas like Haiti are at higher risk for hepatitis B, warranting testing during pregnancy.
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How many factors in this scenario place the client at risk for nutritional deficiencies and the need for dietary guidance and counseling?
- A. Three
- B. Four
- C. Five
- D. Six
Correct Answer: C
Rationale: Five risk factors: adolescence, skipping meals, fast food diet, alcohol consumption, and weight gain concerns increase nutritional deficiency risk.
The nurse correctly explains to the group that the discomfort associated with varicose veins is relieved by which activity?
- A. Resting with the feet in a dependent position
- B. Sitting for periods of time when possible
- C. Putting on calf-length, elastic-top hose
- D. Moving around after standing in one position
Correct Answer: C
Rationale: Elastic-top hose improves venous return, reducing discomfort from varicose veins, unlike dependent positioning or sitting.
The nurse is reviewing the laboratory test results of the pregnant client. Which laboratory test findings would require further follow-up from the nurse?
- A. Hemoglobin
- B. 50-g, 1-hour glucose test
- C. Glucosuria
- D. Proteinuria
Correct Answer: A
Rationale: The normal Hgb level should be 12—16 g/dL in the pregnant client. The nurse should encourage iron-rich foods. The 50-g 1-hour glucose test should be less than 140. Values over 140 warrant a 3-hour glucose screen to determine if the client has gestational diabetes. The presence of glucose in the urine (glucosuria) is negative, which is a normal finding. Proteinuria in trace amounts is common in pregnant women, although higher protein concentrations should be evaluated.
The pregnant client presents with Drag and Drop contractions that she describes as strong in intensity. Her cervical exam indicates that she is dilated to 3 cm. Which conclusion should the nurse make based on this information?
- A. The client is experiencing early labor.
- B. The client is experiencing false labor.
- C. The client has experienced cervical ripening.
- D. The client has experienced lightening.
Correct Answer: A
Rationale: Early labor is a pattern of labor that occurs when contractions become Drag and Drop and the cervix dilates to 3 cm. False labor occurs when Braxton-Hicks contractions are strong enough for the client to believe she is in actual labor. The contractions are infrequent or do not have a definite pattern. The lack of cervical change is also consistent with false labor. The latent phase is characterized by Drag and Drop contractions, although fetal descent may not occur. Cervical ripening (softening, effacement, and increased distensibility) begins about 4 weeks before birth. There is no information in the stem about cervical ripening. Lightening is settling or lowering of the fetus into the pelvis. Lightening can occur a few weeks or a few hours before labor. There is no information in the stem about lightening.
The nurse is providing nutrition counseling to a primigravida who is 10 weeks pregnant. Which meal choice stated by the client indicates she needs additional information?
- A. Black beans, wild rice, collard greens
- B. Dry cereal, milk, dried cranberries
- C. Tuna, broccoli, baked potato
- D. Beef strips, lentils, red peppers
Correct Answer: C
Rationale: Tuna contains mercury and should be limited in pregnancy due to risk of mercury poisoning. The nurse should provide this additional information. Black beans provide a good source of calcium, iron, and protein. Black beans, wild rice, and collard greens provide fiber. Collard greens provide a good source of calcium and folic acid. Dry cereal provides a good source of vitamin D, milk provides a good source of calcium, and dried cranberries provide a good source of calcium and iron. Beef provides a good source of protein and iron, lentils provide a good source of iron, and red peppers provide a good source of vitamin C.
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