A nurse is reinforcing teaching about nutrition with a client who is pregnant and has hyperemesis gravidarum at home.
Which of the following statements indicates that the client understands the teaching?
"I will eat every 6 hours throughout the day.”.
"I will drink water with my meals.”.
"I will limit my protein intake.”.
"I will eat crackers before I get out of bed in the morning.”.
The Correct Answer is D
Choice A rationale:
The statement, "I will eat every 6 hours throughout the day," is not the best approach for a client with hyperemesis gravidarum. Eating at regular intervals may not be well-tolerated in this condition, as frequent nausea and vomiting can make it challenging to keep food down.
Choice B rationale:
The statement, "I will drink water with my meals," is generally a good practice during pregnancy to stay hydrated. However, for a client with hyperemesis gravidarum, it may be advisable to separate fluid intake from meals to minimize the risk of triggering nausea.
Choice C rationale:
The statement, "I will limit my protein intake," is not a recommended approach, especially for a pregnant client. Protein is essential for fetal development, and limiting protein intake may not provide adequate nutrition for the growing fetus.
Choice D rationale:
The statement, "I will eat crackers before I get out of bed in the morning," is a good strategy for managing morning sickness, which is common in pregnancy. Eating plain crackers before getting out of bed can help alleviate nausea and stabilize blood sugar levels.
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Correct Answer is B
Explanation
Choice A rationale:
Placing the client on seizure precautions is not the appropriate action in this scenario. Shaking chills during the immediate postpartum period are not indicative of a seizure. Seizure precautions involve measures like protecting the client from injury during a seizure, such as moving them to a safe area and providing a padded bed or mattress. This is not relevant to the client's current situation of shaking chills.
Choice C rationale:
Covering the client with warm blankets may provide comfort and help raise body temperature if the client is experiencing chills due to being cold. However, it does not address the underlying cause of the shaking chills. The nurse should first assess the client's temperature to determine the cause of the chills before implementing interventions.
Choice D rationale:
Notifying the charge nurse is not the immediate action needed when a client is experiencing shaking chills. The primary responsibility of the nurse in this situation is to assess and identify the cause of the chills. Once the cause is determined, appropriate interventions can be initiated. It's essential to focus on the immediate assessment of the client's condition.
Correct Answer is A
Explanation
Choice A rationale:
When a pregnant client is Rh negative and the newborn is Rh positive, it can lead to Rh incompatibility issues. This occurs when fetal Rh-positive red blood cells enter the maternal circulation during pregnancy or childbirth, causing the mother's immune system to produce antibodies against Rh-positive blood cells. To prevent Rh sensitization, Rho(D) immune globulin is administered to Rh-negative pregnant clients at specific times during pregnancy and postpartum. This administration is essential to prevent hemolytic disease of the newborn in future pregnancies. The Rho(D) immune globulin prevents the mother's immune system from developing antibodies against Rh-positive blood cells, ensuring that the current pregnancy and future pregnancies remain safe. Therefore, choice A is the correct answer.
Choice B rationale:
If the client is Rh positive and the newborn is Rh positive, there is no need for Rho(D) immune globulin administration. Rh incompatibility issues only occur when the mother is Rh negative, and the newborn is Rh positive. Therefore, choice B is not the correct answer.
Choice C rationale:
When both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and therefore, Rho(D) immune globulin administration is unnecessary. This situation is not a reason to administer Rho(D) immune globulin. Choice C is not the correct answer.
Choice D rationale:
If the client is Rh positive and the newborn is Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin administration is not required in this scenario. Choice D is not the correct answer.
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