Asking the client, "How many servings of dairy do you generally consume each day?" Show
The nursing process begins with assessment. Once the nurse knows the number of servings of calcium-rich foods the client consumes each day, the nutritional teaching plan can be personalized to her needs. The daily required intake of calcium for clients younger than 19 years is 1300 mg. This amount can be obtained from 4 cups of milk or yogurt per day. Because there are sources of calcium other than milk, asking whether the client likes milk is not an appropriate first question. Alternative sources of calcium include cheese, yogurt, figs, kale, sardines, orange juice with added calcium, creamy pesto, and cheese sauce. Because the client's daily calcium intake is not known, the number of servings of calcium to be added is also unknown. Upgrade to remove ads Only ₩37,125/year
Terms in this set (30)A nurse is assessing a client who is at 34 weeks gestation and has a mild placental abruption. Which finding should the nurse expect? Dark red vaginal bleeding The nurse should expect the client who has a mild placental abruption to have minimal dark red vaginal bleeding. A nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer? Betamethasone Betamethasone (to stimulate fetal lung maturity and prevent respiratory depression) A nurse is teaching a client who is at 30 weeks of gestation about warning signs of complications that she should report to her provider. Which finding should the nurse include in the teaching? Vaginal bleeding Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a complication such as placental abruption, placenta previa, or preterm labor. A nurse is reviewing the medical record of a client who is at 39 weeks of gestation and has polyhydramnios. Which finding should the nurse expect? Fetal gastrointestinal anomaly Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurologic disorders are expected findings for a fetus experiencing the effects of polyhydramnios. A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which adverse effect should the nurse include in the teaching? Feeling of warmth The nurse should tell the client to expect the feeling of warmth all over her body while the magnesium sulfate is infusing (BP decreases b/c of magnesium, generalized prates could mean an allergic reaction) A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational hypertension. Which finding should the nurse identify as priority? 480 mL urine output in 24 hours Low urine output (<30mL per hour) When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of hypertension, which requires immediate intervention. Therefore, this is the priority finding. A nurse is teaching a client who is at 12 weeks of gestation about the manifestations of potential complications that she should report to her provider. Which information should the nurse include in the teaching? Swelling of the face The nurse should instruct the client to report swelling of the face because this can indicate a hypertensive disorder or preeclampsia A nurse is reviewing lab results for a client who is at 37 weeks of gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic strep, and has a blood type of O negative. Which action should the nurse take? Instruct the client to obtain a rubella immunization after delivery This client is not immune to rubella and should receive this immunization after delivery. A nurse is caring for a client who has oligohydramnios. Which fetal anomaly should the nurse expect? Renal agenesis Oligohydramnios is a volume of amniotic fluid less than 300 mL during the third trimester of pregnancy and occurs when there is a renal system dysfunction or obstructive uropathy. Absence of fetal kidneys will cause oligohydramnios. A nurse is caring for a client who believes she may be pregnant. Which finding should the nurse identify as a positive sign of pregnancy? Palpable fetal movement Palpable fetal movements are a positive sign of pregnancy. Quickening, the client's report of fetal movement, is a presumptive sign of pregnancy. A nurse is assessing a client who is at 37 weeks of gestation and has a suspected pelvic fracture due to blunt abdominal trauma. What finding should the nurse expect? Uterine contractions The nurse should expect the client to be experiencing uterine contractions due to abdominal trauma. A nurse is caring for a client at 26 weeks of gestation and reports constipation. How should the nurse respond? "You should walk for at least 30 min/day" The nurse should encourage the client to participate in moderate physical activity, such as walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation. A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which action should the nurse take? Apply pressure to the client's sacral area during contractions The nurse should provide counter pressure to the sacral area with a palm or a firm object, such as a tennis ball, during contractions. Counterpressure lifts the fetal head away from the sacral nerves, which decreases pain. A nurse is assessing a client who is at 35 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which finding should the nurse report to the provider? DTR +2 Urinary output 20mL/hour The nurse should report a urinary output of 20 mL/hr because this can indicate inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also indicate a decrease in renal perfusion secondary to a worsening of the client's pre-eclampsia. A nurse is teaching a client who is at 10 weeks of gestation about an abdominal ultrasound in the first trimester. What should the nurse include in the teaching? "You will need to have a full bladder during the ultrasound" The nurse should tell the client that a full bladder helps to lift the gravid uterus out of the pelvis during the examination. Therefore, it is important to ensure that the client has a full bladder to obtain the most accurate image of the fetus. A nurse is caring for a client who is at 35 weeks of gestation and has severe pre-eclampsia. Which assessment provides the most accurate reading of fluid and electrolyte status? Daily weight Evidence-based practice indicates that daily weight is the most accurate assessment to determine a client's fluid and electrolyte status. Which lab test confirms pregnancy (edited question)? A urine test for human chorionic gonadotropin Human chorionic gonadotropin is excreted by the placenta and promotes the excretion of progesterone and estrogen. This hormone is the basis for pregnancy testing. A nurse is caring for a client whose LMP began July 8. What is her EDB? April 15 A nurse is caring for a client who is at 38 weeks of gestation and reports no fetal movement for 24hr. What should the nurse do? Auscultate for a FHR Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action. A nurse is assessing a client who is at 12 weeks of gestation and has a hyatidiform mole. What finding should the nurse expect? Dark brown vaginal discharge A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the chorionic villi, which gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters. expect the client to have expected to increased urinary output due to the increase in maternal blood volume and pressure of the uterus on the maternal bladder. no fetal heart tone because viable embryo or fetus isn't present A nurse is caring for a client in their latent phase of labor and is receiving oxytocin via continuous IV infusion. The client is having contractions every 2 min which last 100 to 110 seconds and the FHR is reassuring. What should the nurse do? Decrease the dose of oxytocin by half The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine tachysystole. The nurse should administer oxygen and terbutaline if the FHR is nonreassuring. A nurse is teaching a client who is at 8 weeks of gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. What information should they include in the teaching? The fibroid can increase the risk for postpartum hemorrhage Uterine fibroids can increase the risk for postpartum hemorrhage due to the increase in blood supply to the uterus, which supports the fibroid. A nurse is providing teaching to a client who is at 8 weeks of gestation about manifestations to report to the provider during pregnancy. What information should the nurse include in the teaching? Blurred or double vision A client who is pregnant should report experiencing blurred or double vision as these could be a manifestation of gestation hypertension or pre-eclampsia. A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take? Obtain blood samples for baseline laboratory values The nurse should obtain samples of the client's blood for baseline testing of hemoglobin and hematocrit levels. A nurse is teaching a client who is at 12 weeks of gestation and has HIV. What should the nurse include in the teaching? "You should continue to take zidovudine throughout the pregnancy" The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmission of HIV to her newborn. A nurse is teaching a client who is 13 week of gestation about the treatment of incompetent cervix with cervical cerglage. Which statement by the client indicates an understanding? "I should go to the hospital if I think I may be in labor" Cervical cerclage prevents premature opening of the cervix during pregnancy. The client should immediately go to a facility for evaluation if she experiences any manifestations of labor while the cerclage is in place. If the client experiences preterm uterine contractions she might require tocolytic therapy. A nurse is caring for a client in active labor and has mec stained fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor. What should the nurse do? Prepare equiment needed for newborn resuscitation The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery. The nurse should know that routine suctioning of the newborn's mouth and nose while the head is on the maternal perineum is no longer recommended. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery. A nurse is caring for a client who is at 39 weeks of gestation and is in the active phase of labor. The nurse observes late decals in the FHR. Which finding causes late decels? Uteroplacental insufficiency A late deceleration in the FHR is a nonreassuring FHR pattern resulting from fetal hypoxemia due to insufficient placental perfusion. The nurse should reposition the client, initiate oxygen, and increase the infusion rate of IV fluid to enhance placental perfusion. (Edited question) which order should be questioned with placenta previa? Perform a vaginal exam When a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding. A nurse is caring for a client at 37 weeks and is undergoing a nonstress test. The FHR is 130 without accelerations for the past 10 min. What should the nurse do? Use vibroacoustic stimulation on the client's abdomen for 3 seconds The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR. 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The patient denies having diabetes or lupus, and the fetus appears otherwise normal. What other factor could play a role in the growth of this fetus? 7 answers When preparing to listen to the fetal heart rate at 12 weeks gestation the nurse would use which of the following?Around 12 weeks into your pregnancy, you've nearly reached the end of the first trimester, and your obstetrician will use an ultrasound device known as a fetal Doppler to check for your baby's heartbeat. Hearing the heartbeat for the first time is, in a word, thrilling.
Where should the nurse expect to Auscultate the fetal heart tones?Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be in the right upper quadrant. A nurse on a labor unit is admitting a client who reports painful contractions.
When can the heartbeat of the fetus first be heard through a stethoscope quizlet?When can a primigravida fetal heartbeat be heard for the first time? A fetal heartbeat can be obtained at 10 to 12 weeks with electronic Doppler ultrasound. The heartbeat cannot be obtained with a stethoscope, and 4 weeks is too early to hear a fetal heart. A fetoscope cannot pick up the heartbeat until the 17th week.
In which of the following maternal quadrants should the nurse Auscultate fetal heart tones?Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundal portion of the uterus and a long, smooth surface on the mother's right side. In which of the following maternal quadrants should the nurse auscultate fetal heart tones? - Right upper quadrant.
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When preparing to listen to the fetal heart rate at 12 weeks gestation the nurse would use which of the following quizlet?
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