A nurse is teaching a client who is at 10 weeks of gestation about
nutrition during pregnancy. Which of the following statements by the
client indicates an understanding of the teaching?
a) “I should increase my protein intake to 60 grams each day.”
b) “I should drink 2 liters of water each day.”
c) “I should increase my overall daily caloric intake by 300 calories.”
d) “I should take 600 micrograms of folic acid each day.” – ANSWER\u0002d) “I should take 600 micrograms of folic acid each day.”
Rationale: A client who is pregnant should increase folic acid intake
to 600 mcg daily. Folic acid assists with preventing neural tube birth
defects.
A client who is pregnant should increase protein intake to 71 g each
day during the second and third trimesters.
A client who is pregnant should consume 3 L of water each day.
A client who is pregnant should increase caloric intake by 340 cal
during the second trimester and by 452 cal during the third
trimester.
A nurse is assessing a late preterm newborn. Which of the following
manifestations is an indication of hypoglycemia?
a) Hypertonia
b) Increased feeding
c) Hyperthermia
d) Respiratory distress – ANSWER- d) Respiratory distress
Rationale: Late preterm newborns are at an increased risk for
hypoglycemia due to decreased glycogen stores and immature
insulin secretion. Respiratory distress is a manifestation of
hypoglycemia. Other manifestations of hypoglycemia include an
abnormal cry, jitteriness, lethargy, poor feeding, apnea, and
seizures.
A hypoglycemic newborn can exhibit HYPOtonia, POOR feeding
behaviors, and HYPOthermia.
A nurse in a prenatal clinic is assessing a group of clients. Which of the
following clients should the nurse see first?
a) A client who is at 11 weeks of gestation and reports abdominal
cramping
b) A client who is at 15 weeks of gestation and reports tingling and
numbness in right hand
c) A client who is at 20 weeks of gestation and reports constipation for
the past 4 days
d) A client who is at 8 weeks of gestation and reports having three
bloody noses in the past week – ANSWER- a) A client who is at 11
weeks of gestation and reports abdominal cramping
Rationale: Abdominal cramping can indicate an ectopic pregnancy
or manifestations of spontaneous abortion. The nurse should
request that the provider see this client first.
The other three findings are common discomforts related to
pregnancy for their gestation.
A nurse is demonstrating to a client how to bathe their newborn. In
which order should the nurse perform the following actions? –
ANSWER- The nurse should demonstrate how to bathe a newborn by
using a head to toe, clean to dirty, approach. Therefore, the nurse should
first wipe the newborn’s eyes from the inner canthus outward using plain
water. The nurse should then wash the newborn’s neck by lifting the
newborn’s chin. Next, the nurse should cleanse the skin around the
umbilical cord stump followed by washing the newborn’s legs and feet.
The last step of the bath should be to clean the newborn’s diaper area.
A nurse is teaching a newly licensed nurse about collecting a specimen
for the universal newborn screening. Which of the following statements
should the nurse include in the teaching?
a) “Obtain an informed consent prior to obtaining the specimen.”
b) “Collect at least 1 milliliter of urine for the test.”
c) “Ensure that the newborn has been receiving feedings for 24 hours
prior to obtaining the specimen.”
d) “Premature newborns may have false negative tests due to immature
development of liver enzymes.” – ANSWER- c) “Ensure that the
newborn has been receiving feedings for 24 hours prior to obtaining the
specimen.”
Rationale: The nurse should ensure that the newborn has been
receiving regular feedings for at least 24 hr prior to testing.
The universal newborn screening is mandated by law for all
newborns. Therefore, the nurse does not need to obtain informed
consent prior to obtaining the specimen.
The nurse should collect a capillary blood sample via heel stick for
the newborn screening. Urine is not collected for this test.
Premature newborns have a delayed development of liver enzymes
which can cause a false POSITIVE result<\/p>\n\n\n\n
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