A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?

"A gain of about 1 pound per week is the best pattern for you."

"It would be best if you gained about 11 to 20 pounds."

"The recommendation for you is about 15 to 25 pounds."

"A gain of about 25 to 35 pounds is recommended for you."

Answer and Explanation

The Correct Answer is C

Choice A: A weight gain of about 1 pound per week is a general guideline for women with normal BMI. However, for a client with a BMI of 26.5, the recommended weight gain during pregnancy may differ.
Choice B: Gaining 11 to 20 pounds may not be sufficient for a client with a BMI of 26.5, as the recommended weight gain is slightly higher for women with a higher prepregnancy BMI.

Choice C: For a client with a BMI of 26.5, the recommended weight gain during pregnancy is approximately 15 to 25 pounds. This range is specific to women with a BMI in the overweight category.
Choice D: Gaining 25 to 35 pounds is recommended for clients with a lower BMI range (normal BMI). For a client with a BMI of 26.5, this amount of weight gain may be excessive.

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Correct Answer is B

Explanation

A. Maintain the client in the lithotomy position: The lithotomy position is not typically

maintained during the active phase of labor. It is used during the pushing stage (second stage) of labor.
B. Encourage the client to empty her bladder every 2 hr: A full bladder can impede fetal descent and progress during labor, so encouraging the client to empty her bladder regularly is essential.
C. Remind the client to bear down with each contraction: Bearing down during the active phase of labor is not appropriate, as it may lead to premature pushing and cervical swelling.
D. Perform vaginal examinations frequently: Frequent vaginal examinations can increase the risk of infection and should be minimized during labor.

A. Position the client on her side. B. Elevate the client's legs. C. Increase the infusion rate of the IV fluid. D. Administer oxygen via face mask.

Correct Answer is A

Explanation

A. Position the client on her side: Late decelerations are often associated with uteroplacental insufficiency, which may be improved by changing the maternal position to improve blood flow to the placenta.
B. Elevate the client's legs: Elevating the client's legs would not directly address the cause of late decelerations.
C. Increase the infusion rate of the IV fluid: While ensuring adequate hydration is important, it is not the priority action when late decelerations are noted.
D. Administer oxygen via a face mask: Oxygen administration may be necessary, but it is not the priority action. Positioning the client on her side to improve blood flow is the priority.

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A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

Correct Answer is B

Explanation

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

Correct Answer is A

Explanation

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