A nurse is caring for a client who is at 10 weeks of gestation and reports nausea and vomiting on most days.
Which of the following recommendations should the nurse make?
Keep your environment well ventilated.
Eat three large meals each day.
Restrict intake of high-carbohydrate foods.
Brush your teeth immediately after eating.
The Correct Answer is A
Keep your environment well ventilated. This can help reduce nausea and vomiting by eliminating odors that might trigger them.
Some additional explanations are:
Choice B is wrong because eating three large meals each day can increase nausea and vomiting by overloading the stomach. It is better to eat small, frequent meals and avoid spicy, greasy, or strong-smelling foods.
Choice C is wrong because restricting intake of high-carbohydrate foods can lead to ketosis, which can worsen nausea and vomiting. High-carbohydrate foods can also help settle the stomach and provide energy.
Choice D is wrong because brushing your teeth immediately after eating can stimulate the gag reflex and cause nausea and vomiting. It is better to rinse your mouth with water or mouthwash after eating and brush your teeth at least an hour later.
Normal ranges for nausea and vomiting in pregnancy are:
- Nausea and vomiting usually start around 6 weeks of gestation and peak around 9 weeks. They usually subside by 16 to 20 weeks, but some women may experience them throughout pregnancy.
- Nausea and vomiting are considered mild if they do not interfere with daily activities or nutrition. They are considered moderate if they cause some difficulty with daily activities or nutrition. They are considered severe if they prevent adequate intake of fluids and nutrients, cause weight loss, dehydration, electrolyte imbalance, or ketonuria.
- Nausea and vomiting that are severe or persist beyond 20 weeks of gestation may indicate a complication such as hyperemesis gravidarum, molar pregnancy, multiple gestation, or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The task involves making ongoing judgments about client data. This is a contraindication to delegating a task to an AP because the AP is not trained or authorized to make clinical decisions or assessments. The nurse is responsible for evaluating the client’s condition and needs, and delegating only tasks that are within the AP’s scope of practice and do not require critical thinking.
Choice B is wrong because the task is within the AP’s range of function to perform.
This is a criterion for delegating a task to an AP, not a contraindication. The nurse should ensure that the AP has the necessary skills and knowledge to perform the task safely and effectively.
Choice C is wrong because the task can be performed in the same manner for most clients.
This is also a criterion for delegating a task to an AP, not a contraindication. The nurse should delegate tasks that are routine, standardized, and have predictable outcomes.
Choice D is wrong because the task requires a specific sequence of steps.
This is not a contraindication to delegating a task to an AP, as long as the AP is competent and familiar with the procedure. The nurse should provide clear instructions and expectations for the task, and monitor the AP’s performance.
Correct Answer is B
Explanation
Observe the client’s body language during the conversation. This action will help the nurse to assess the client’s nonverbal cues and emotions, which can enhance communication and understanding. The nurse should also determine the client’s understanding several times during the conversation and use lay terms if possible.
Choice A is wrong because avoiding asking the client personal questions can hinder rapport building and prevent the nurse from obtaining important information about the client’s health and needs.
Choice C is wrong because maintaining eye contact with the interpreter when asking questions can show disrespect and disinterest to the client and his family. The nurse should look at the client and his family when asking questions, not at the interpreter.
Choice D is wrong because including medical terminology when discussing the client’s condition can confuse the client and his family and create barriers to communication. The nurse should use simple and clear language that the client and his family can understand.
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