32. Which client statement on cultural or religious influences on nutrition requires intervention?

1.   “I avoid milk and meat at meals because I am Jewish.”

2.   “My auntie sent me clay from the south to eat every day.”

3.   “Because I am Muslim, I do not ever eat any pork products.”

4.   “My grandmother makes sure I eat a serving of greens each day.”

____  33.   When preparing nutritional instruction, which pregnant client should the nurse consider the highest priority?

1.   40-year-old gravida 2

2.   35-year-old gravida 4

3.   15-year-old nulligravida

4.   22-year-old primigravida

____  34.   Which statement is best to include when teaching a pregnant adolescent about nutritional needs?

1.   “You just need to pay attention to what you eat now.”

2.   “Folic acid intake is the key to having a healthy baby.”

3.   “It is important eat iron-rich foods like meat every day.”

4.   “Calcium and milk aren’t needed until the third trimester.”

____  35.   The nurse is caring for a pregnant teen. What should the nurse do to accurately assess the teen’s nutritional intake?

1.   Assess laboratory values.

2.   Ask about cooking facilities.

3.   Observe for clinical signs of malnutrition.

4.   Ask to complete a dietary recall to identify eating patterns.

____  36.   The nurse is leading a session on nutrition for postpartum clients. Which statement indicates that teaching has been effective?

1.   “Breastfeeding requires that I eat lots of protein daily.”

2.   “Because I am breastfeeding, I need a low calcium intake.”

3.   “Since I am bottlefeeding, I don’t have to eat vegetables.”

4.   “Bottlefeeding moms like me require a high sodium intake.”

____  37.   The nurse is preparing a prenatal class about infant feeding methods to include maternal nutritional requirements for breastfeeding and formula-feeding. What statement should the nurse include?

1.   “Formula-feeding mothers need a high protein intake to avoid fatigue.”

2.   “Producing breast milk requires calories, but any source of food is fine.”

3.   “Breastfeeding requires a continued high intake of protein and calcium.”

4.   “Formula-feeding mothers should protect their health with a lot of calcium.”

____  38.   The nurse is responding to phone calls. Which call should the nurse return first?

1.   29 weeks’ gestation, reports increased fetal movement

2.   37 weeks’ gestation, reports no fetal movement for 24 hours

3.   18 weeks’ gestation, reports decreased fetal movement for 2 days

4.   35 weeks’ gestation, reports decreased fetal movement for 1 hour

____  39.   A woman at 28 weeks’ gestation reports not feeling the baby move for over 30 minutes. How should the nurse respond first?

1.   “You need to call your physician for a stat ultrasound.”

2.   “Have you been smoking?”

3.   “Your baby might be asleep.”

4.   “You need to go to the emergency room immediately for further evaluation.”

____  40.   The nurse is preparing a client in her second trimester for a three-dimensional ultrasound examination. Which statement indicates that teaching had been effective?

1.   “I might be able to see who the baby looks like with the ultrasound.”

2.   “If the ultrasound is normal, it means my baby has no abnormalities.”

3.   “The nuchal translucency measurement will diagnose Down syndrome.”

4.   “Measuring the length of my cervix will determine if I will deliver early.”

____  41.   A pregnant client’s fundal height is 26 cm at 32 weeks’ gestation. Why would the healthcare provider schedule this client for sonograms every 2 weeks?

1.   Evaluate fetal growth

2.   Determine fetal presentation

3.   Assess for congenital anomalies

4.   Rule out a suspected hydatidiform mole

____  42.   What should the nurse do when assisting a pregnant client who is having an abdominal ultrasound to determine fetal age?

1.   Has the woman empty her bladder before the test begins

2.   Assists the woman into a supine position on the examining table

3.   Asks the woman to sign an operative consent form prior to the procedure

4.   Instructs the woman to eat a fat-free meal 2 hours before the scheduled test time

____  43.   At 32 weeks’ gestation, a woman is scheduled for a second non-stress test. Which client response indicates an adequate understanding of this procedure?

1.   “I’ll have an IV started before the test.”

2.   “I need to have a full bladder for this test.”

3.   “I should schedule this test during a time when my infant is most active.”

4.   “I must avoid drinks containing caffeine for 24 hours before the test.”

____  44.   During a non-stress test, the nurse notes that the fetal heart rate decelerates about 15 beats during a period of fetal movement. The decelerations occur twice during the test and last 20 seconds each. What should the nurse expect the outcome of this test will be?

1.   A reactive test

2.   A negative test

3.   An equivocal test

4.   A nonreactive test

____  45.   A pregnant woman is having a nipple-stimulated contraction stress test. Which result indicates hyperstimulation?

1.   There are more than five fetal movements in a 10-minute period.

2.   There are more than five uterine contractions in a 10-minute period.

3.   The fetal heart rate accelerates when contractions last up to 60 seconds.

4.   The fetal heart rate decelerates when three contractions occur within a 10-minute period.

____  46.   The nurse is reviewing nursing documentation related to the care of a client who had an amniocentesis. Which nursing note reflects appropriate client care?

1.   Prior to discharge, the client demonstrated vaginal spotting.

2.   An Rh-positive client received RhoGAM after the amniocentesis.

3.   The client was monitored for 30 minutes after completion of the test.

4.   The client reported that she takes insulin before each meal and at bedtime.

____  47.   How should the nurse interpret a pregnant client’s lecithin/sphingomyelin (L/S) ratio finding of 2:1 on amniotic fluid?

1.   Fetal lungs are mature.

2.   Fetal lungs are still immature.

3.   The fetus has a congenital anomaly.

4.   The fetus is small for gestational age.

____  48.   A client with a normal prepregnancy weight asks why she has been told to gain 25 to 35 pounds during her pregnancy, but her underweight friend was told to gain 28 to 40 pounds. What should the nurse explain as being the recommended weight gain during pregnancy?

1.   More than 25 to 35 pounds for an overweight client

2.   More than 25 to 35 pounds for an underweight woman

3.   25 to 35 pounds, regardless of a client’s prepregnancy weight

4.   The same for a normal-weight woman as for an overweight woman

____  49.   Which of the following tests provides information about the fetal number?

1. Amniocentesis

2. Standard second-trimester sonogram

3. Beta hCG

4. Maternal serum alpha-fetoprotein

____  50.   Which of the following tests has become a widely accepted method of evaluating fetal status?

1. Contraction stress test (CST)

2. MSAFP test

3. Non-stress test (NST)

4. Nuchal translucency test