A nurse is reinforcing teaching with a client who has a pre-pregnancy BMI of 21. How much weight should the nurse recommend the client gain during the course of the pregnancy?

16.4 to 20.5 kg (36 to 45 lb)

5 to 7.7 kg (11 to 17 lb)

11.4 to 15.9 kg (25 to 35 lb)

8.2 to 10.9 kg (18 to 24 lb)

Answer and Explanation

The Correct Answer is C

A. A weight gain of 16.4 to 20.5 kg (36 to 45 lb) is excessive for a client with a pre-pregnancy BMI of 21, which falls within the normal range. Such weight gain is more appropriate for an underweight client.

B. A weight gain of 5 to 7.7 kg (11 to 17 lb) is inadequate for a client with a normal pre-pregnancy BMI. This range is suitable for an overweight or obese client.

C. A pre-pregnancy BMI of 21 falls within the normal range (18.5–24.9), and the recommended weight gain for clients in this category is 11.4 to 15.9 kg (25 to 35 lb). This range supports healthy fetal growth and reduces the risk of complications.

D. A weight gain of 8.2 to 10.9 kg (18 to 24 lb) is slightly below the recommended range for a client with a normal BMI and may not adequately support fetal development. This range is more appropriate for overweight individuals.

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Correct Answer is D

Explanation

A: Administering the medication into the deltoid muscle is not recommended for newborns due to their underdeveloped muscle mass and the potential for injury. The vastus lateralis muscle in the thigh is the preferred site for intramuscular injections in infants.

B: Checking the mother's Rh factor is not directly related to the administration of phytonadione, which is given to prevent vitamin K deficiency bleeding in the newborn, a condition unrelated to the mother's Rh factor.

C: Administering the medication 12 hours after birth is not the standard practice. Phytonadione is typically given within the first hour after birth to ensure prompt prevention of hemorrhagic disease of the newborn.

D: Administering the medication with a 25 gauge needle is appropriate as it is small enough to cause minimal discomfort and large enough to ensure proper delivery of the medication into the infant's muscle tissue.

A. Suprapubic area B. Umbilical area C. Above the left iliac crest D. Below the liver border on the right abdomen E. None F. None

Correct Answer is A

Explanation

A. At 12 weeks of gestation, the uterus has enlarged but is still mostly within the pelvis. Fetal heart tones are best auscultated over the suprapubic area using a Doppler, as the fundus has not yet risen to the level of the umbilicus.

B. The umbilical area corresponds approximately to 20 weeks gestation, so the fetal heart tones would not be audible there at 12 weeks.

C. Auscultating above the iliac crest would likely be too high at 12 weeks, as the uterus has not yet reached this level.

D. The area below the liver border on the right abdomen is too high for early gestation; fetal heart tones would not be reliably heard in this location at 12 weeks.

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A nurse is reinforcing teaching with a client who has a pre-pregnancy BMI of 21. How much weight should the nurse recommend the client gain during the course of the pregnancy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer phytonadione to a newborn. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is auscultating fetal heart tones with a Doppler device for a client who is at 12 weeks of gestation. Where should the nurse expect to auscultate the fetal heart tones?

Correct Answer is A

Explanation

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