A nurse is caring for a client who is pregnant.
Nurses' Notes 1000:
The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks.
1015:
IV fluids initiated. Prochlorperazine administered via intermittent IV bolus.
1100:
Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine.
The nurse is providing discharge teaching to the client.
For each discharge instruction, specify if each action is recommended or contraindicated for the client.
Alternate eating solid foods and liquids
Eat every 2 to 3 hr
Drink warm ginger ale when nauseated
Increase intake of high-fat foods
Recommended actions
Correct Answer : A,B,C,E
Correct answer: A, B, C, E
Rationale:
- A: Alternate eating solid foods and liquids is recommended. This can help prevent dehydration and malnutrition, as well as reduce the risk of vomiting by avoiding overfilling the stomach.
- B: Eat every 2 to 3 hr is recommended. This can help maintain blood glucose levels and prevent hunger-induced nausea.
- C: Drink warm ginger ale when nauseated is recommended. Ginger has antiemetic properties and can help soothe the stomach and reduce nausea.
- E: Recommended actions is correct. The nurse should indicate which actions are recommended for the client.
- D: Increase intake of high-fat foods is contraindicated. High-fat foods can delay gastric emptying and worsen nausea and vomiting. The client should eat low-fat, bland, and easy-todigest foods instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- A. The LPN and AP lower the side rails before lifting the client up in bed is incorrect. This is a safe practice that prevents injury to the client and staff by providing more space for movement and reducing the risk of falling.
- B. Prior to lifting the client, the LPN and AP raise the bed to waist level is incorrect. This is a safe practice that prevents injury to the client and staff by reducing the need for bending and lifting.
- C. The LPN and the AP grasp the client under his arms to lift him up in bed is correct. This is an unsafe practice that can cause injury to the client's shoulders, neck, and axillae by applying excessive pressure and friction. The LPN and AP should use a draw sheet or a mechanical lift device to move the client up in bed.
- D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift is incorrect. This is a safe practice that encourages active participation from the client and reduces the workload for the staff by using leverage.
Correct Answer is A
Explanation
Choice A rationale:
Irritability is a common withdrawal symptom in newborns exposed to cocaine during pregnancy. Cocaine exposure can lead to irritability, restlessness, and difficulty in consoling the newborn.
Choice B rationale:
Hypotonicity, or decreased muscle tone, is not a common finding associated with cocaine exposure in newborns. Cocaine exposure more commonly results in hypertonicity, where the muscles are tense and rigid.
Choice C rationale:
Decreased auditory startle response is not a typical finding associated with cocaine exposure. Newborns exposed to cocaine may have an exaggerated startle response, which is the opposite of the expected finding in this case.
Choice D rationale:
Increased head circumference is not a characteristic finding associated with cocaine exposure. Cocaine exposure is more likely to cause growth restriction, low birth weight, and microcephaly (small head size) in newborns.
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