The nurse prepares to counsel a 14-year-old patient who is 16 weeks pregnant regarding nutrition.
Which action would be appropriate for the nurse to take first?

Explain the importance of adequate nutrition for the patient’s own growth and development.

Explain the relationship between the patient’s eating habits and fetal development.

Ask what the patient ate and drank within the last day or two.

Discuss with the patient the basic nutritional requirements of pregnancy.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Ask what the patient ate and drank within the last day or two.This is because the nurse needs to assess the patient’s current nutritional status and eating habits before providing any education or advice.The nurse can then tailor the counseling to the patient’s specific needs and preferences.

Choice A is wrong because it is not the first action that the nurse should take.While it is important to explain the importance of adequate nutrition for the patient’s own growth and development, this should be done after assessing the patient’s current situation.

Choice B is wrong because it is not the first action that the nurse should take.While it is important to explain the relationship between the patient’s eating habits and fetal development, this should be done after assessing the patient’s current situation.

Choice D is wrong because it is not the first action that the nurse should take.While it is important to discuss with the patient the basic nutritional requirements of pregnancy, this should be done after assessing the patient’s current situation.

The normal ranges for nutritional intake during pregnancy vary depending on the age, weight, activity level, and health status of the patient.

However, some general guidelines are:

• Increase calorie intake by about 300 calories per day

• Increase protein intake by about 25 grams per day

• Increase calcium intake by about 1000 milligrams per day

• Increase iron intake by about 27 milligrams per day

• Increase folic acid intake by about 600 micrograms per day

• Increase fluid intake by about 8 to 10 cups per day

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Correct Answer is C

Explanation

The correct answer is choice C. Assess the client’s blood pressure.Methylergonovine is a uterotonic medication that can cause hypertension and is contraindicated for clients with preeclampsia or cardiac disease.

Therefore, the nurse should check the client’s blood pressure before administering this medication to ensure it is within normal range (120/80 mm Hg or lower).

Choice A is wrong because assessing the client’s pain scale is not a priority assessment before giving methylergonovine.

Pain is not a contraindication for this medication and does not affect its effectiveness.

Choice B is wrong because assessing the client’s respiratory rate is not a priority assessment before giving methylergonovine.

Respiratory rate is not affected by this medication and does not indicate any adverse effects.

Choice D is wrong because assessing the client’s last bowel movement is not a priority assessment before giving methylergonovine.

Bowel movement is not related to postpartum hemorrhage or uterine atony, which are the indications for this medication.

A. Observe the patient for vaginal discharge of bright red blood. B. Assess the patient’s vaginal tone. C. Massage the patient’s perineum. D. Apply petrolatum to the patient’s perineum.

Correct Answer is D

Explanation

The correct answer is choice D. Apply petrolatum to the patient’s perineum.This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery.Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.

Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care.Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.

Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care.Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.

Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care.Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids.Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.

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The nurse prepares to counsel a 14-year-old patient who is 16 weeks pregnant regarding nutrition. Which action would be appropriate for the nurse to take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with postpartum hemorrhage. The provider has ordered Methylergonovine 200 mcg intravenously to be administered stat. The nurse should perform which priority assessment prior to administering this medication?

Correct Answer is C

Explanation

During the postpartal admission assessment, the nurse notes that a patient’s perineum appears edematous and ecchymotic. Based on this finding, which action should the nurse take?

Correct Answer is D

Explanation

A woman gives birth to twin girls, one of whom is stillborn. Which nursing action would be least helpful in supporting the woman as she copes with her loss?

The nurse suspects drug abuse in a patient admitted with no prenatal care and a diagnosis of abruptio placentae.Which question would elicit the most information from the patient concerning the suspected drug use?

A 23-year-old primigravida who appears to be in her third trimester of pregnancy comes to the labor and delivery unit reporting acute abdominal pain. She has had no prenatal care. Which assessment should the nurse do first?

he nurse instructs a woman who is attending the infertility clinic about strategies designed to facilitate conception. Which statement by the patient would indicate that she understands the instructions?

A nurse is caring for a client with gestational diabetes.Which guideline should the nurse use when providing nutritional counseling to this client?

A client who is 22 weeks pregnant with a twin gestation comes to the clinic. The nurse instructs the client in self-care for the third trimester of pregnancy. Which statement made by the client would indicate the need for further teaching?

A nurse is observing the internal fetal monitor readings of a laboring client.The fetal heart rate is between 130 and 138 beats per minute, with moderate beat-to-beat variability. How should the nurse interpret this finding?

The nurse prepares to counsel a 14-year-old patient who is 16 weeks pregnant regarding nutrition.
Which action would be appropriate for the nurse to take first?