A nurse is assisting in the plan of care for a client who is pregnant and has phenylketonuria (PKU). Which of the following actions should the nurse include in the plan of care?

Prepare the client for a cesarean birth

Monitor blood glucose levels daily

Reinforce teaching about a protein-free diet.

Administer thyroid hormone replacement.

Answer and Explanation

The Correct Answer is C

A. Prepare the client for a caesarean birth. Caesarean birth is not routinely required for clients with PKU unless there are obstetric indications. Vaginal delivery is usually possible.

B. Monitor blood glucose levels daily. PKU involves the inability to metabolize phenylalanine, not glucose. Monitoring glucose is important in clients with diabetes, not PKU.

C. Reinforce teaching about a protein-free diet. Phenylketonuria (PKU) is a metabolic disorder where the body cannot break down the amino acid phenylalanine. During pregnancy, it is crucial to maintain low phenylalanine levels to prevent harm to the developing fetus. Therefore, a diet low in phenylalanine (not protein-free, but low in phenylalanine) is essential.

D. Administer thyroid hormone replacement. Thyroid hormone replacement is not related to PKU management. It is used for clients with thyroid conditions such as hypothyroidism.

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Correct Answer is C

Explanation

A. Give herself a hypertonic enema the day before the procedure. A hypertonic enema is not required for an amniocentesis. In fact, enemas are not part of the preparation for this procedure.

B. Wash her abdomen with soap and water the morning of the procedure. While general hygiene is always recommended, specific cleansing of the abdomen is not necessary for an amniocentesis.

C. Empty her bladder immediately prior to the procedure. At 23 weeks of gestation, the bladder should be emptied to prevent accidental puncture during the amniocentesis.

D. Refrain from eating breakfast the day of the procedure. Fasting is not necessary for an amniocentesis; the client can eat normally before the procedure.

A. The client will be asked to stimulate her nipples for 5 min during the test. B. The client will receive an ultrasound prior to the test. C. An IV will be initiated prior to the test. D. An external fetal monitor will be used to monitor the FHR.

Correct Answer is D

Explanation

A. The client will be asked to stimulate her nipples for 5 min during the test. Nipple stimulation is used during a contraction stress test, not a nonstress test. The nonstress test only monitors the fetal heart rate without inducing contractions.

B. The client will receive an ultrasound prior to the test. An ultrasound is not a routine part of a nonstress test. The nonstress test only involves monitoring the fetal heart rate using an external monitor.

C. An IV will be initiated prior to the test. An IV is not necessary for a nonstress test as it is a noninvasive procedure that only requires external monitoring of the fetal heart rate.

D. An external fetal monitor will be used to monitor the FHR. A nonstress test involves the use of an external fetal monitor to assess the fetal heart rate and its response to fetal movements. This helps determine fetal well-being.

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A nurse is assisting in the plan of care for a client who is pregnant and has phenylketonuria (PKU). Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is at 23 weeks of gestation and will return to the facility the following week for an amniocentesis. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who is scheduled for a nonstress test. Which of the following information should the nurse include?

Correct Answer is D

Explanation

How is the estimated due date in pregnancy calculated?

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