NURSING 101 NCLEX-RN

A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?

A.     She is compliant with her diet as previously taught.

B.     She needs further instruction and reinforcement.

C.    She needs to increase her caloric intake.

D.    She needs to be placed on a restrictive diet immediately.

Correct Answer: B Section: (none) Explanation

Explanation/Reference:

Explanation:

(A) She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. (B) Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 2730 lb over the 9-month period. With rapid and excessive weightgain, PIH should also be suspected. (C) She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. (D) Restrictive dieting is not recommended during pregnancy.

QUESTION 5

Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is:

A.     70 mg/dL and 120 mg/dL

B.     100 mg/dL and 200 mg/dL

C.    40 mg/dL and 130 mg/dL

D.    90 mg/dL and 200 mg/dL

Correct Answer: A Section: (none) Explanation

Explanation/Reference:

Explanation:

(A) The recommended range is 70120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels are not recommended. The higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus.

QUESTION 6

When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?

A.     Continue monitoring because this is a normal occurrence.

B.     Turn client on right side.

D. Report to physician or midwife.

Correct Answer: D Section: (none) Explanation

Explanation/Reference:

Explanation:

(A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. (C) IV fluids should be increased, not decreased. (D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.

QUESTION 7

The predominant purpose of the first Apgar scoring of a newborn is to:

A.     Determine gross abnormal motor function

B.     Obtain a baseline for comparison with the infant's future adaptation to the environment

C.    Evaluate the infant's vital functions

D.    Determine the extent of congenital malformations

Correct Answer: C Section: (none) Explanation

Explanation/Reference:

Explanation:

(A) Apgar scores are not related to the infant's care, but to the infant's physical condition. (B) Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. (C) The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. (D) Congenital malformations are not one of the areas assessed with Apgar scores.

QUESTION 8

A pregnant woman at 36 weeks' gestation is followed for PIH and develops proteinuria. To increase protein in her diet, which of the following foods will provide the greatest amount of protein when added to her intake of 100 mL of milk?