The nurse provides a 16-year-old client with information concerning expected and possible changes during pregnancy.
Which statement, if made by the client, would indicate that she understands the information?
“I should expect a few spots of blood on my underwear because I have more blood in my body now.”.
“Clear fluid will leak from my vagina if my baby is surrounded by too much water in my womb.”.
“If I begin to see dark patches on my face, it means that my blood pressure is rising.”.
“If I feel like I have butterflies in my stomach, it means my baby is moving.”.
The Correct Answer is D
The correct answer is choice D. If the client feels like she has butterflies in her stomach, it means her baby is moving.
This is a normal and expected change during pregnancy, especially in the second and third trimesters. The baby’s movements can be felt as flutters, kicks, or rolls.
Choice A is wrong because spotting of blood on the underwear is not a normal change during pregnancy.
It can indicate a problem such as placenta previa, placental abruption, or miscarriage. Any bleeding during pregnancy should be reported to the health care provider.
Choice B is wrong because clear fluid leaking from the vagina is not a normal change during pregnancy.
It can indicate that the membranes have ruptured and amniotic fluid is escaping.
This can lead to infection and preterm labor if not treated promptly. Any fluid leakage during pregnancy should be reported to the health care provider.
Choice C is wrong because dark patches on the face are not a sign of high blood pressure during pregnancy.
They are called melasma or chloasma and are caused by increased pigmentation due to hormonal changes. They usually fade after delivery and are not harmful. High blood pressure during pregnancy can cause symptoms such as headache, blurred vision, swelling, and protein in the urine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because the first priority for a pregnant woman with acute abdominal pain is to assess the fetal well-being and rule out any obstetric complications such as placental abruption, uterine rupture, or preterm labor.Fetal heart tones can indicate the presence and viability of the fetus and alert the nurse to any signs of fetal distress or hypoxia.
Choice A: Obtain a full history is wrong because it is not the most urgent action.
A full history can provide valuable information about the possible causes of abdominal pain, but it should not delay the assessment of fetal status and maternal vital signs.
Choice B: Examine the cervix for dilation is wrong because it can be harmful in some cases.A digital cervical examination should be avoided until placenta previa is ruled out by ultrasound, as it can cause bleeding and worsen the condition.
Moreover, cervical dilation alone does not indicate the cause or severity of abdominal pain.
Choice D: Palpate for uterine contraction frequency is wrong because it is not the most reliable method to assess labor.Uterine contractions can be measured by external tocodynamometry or internal intrauterine pressure catheter, which can provide more accurate and objective data than manual palpation.
Furthermore, uterine contractions do not necessarily indicate labor, as they can also be caused by other conditions such as dehydration, infection, or irritable uterus.
Correct Answer is C
Explanation
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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