SHEET FULL SOLUTIONS CORRECT ANSWERS
PREPARATION SET
◉ The nurse is educating client who has been diagnosed with
pregnancy-induced hypertension (PIH) and placed on a sodium
restriction. Which statement by the client indicates that the teaching
has been effective?
A. "I should avoid eating potato chips."
B. "I should limit sodium intake to correct my hypotension."
C. "Too much sodium can cause central nervous system
malformations."
D. "Consuming canned foods will help reduce my sodium levels.".
Answer: A. "I should avoid eating potato chips."
Sodium restriction is often not necessary for pregnant clients, unless
they are at an increase risk of pregnancy-induced hypertension
(PIH). Teaching has been effective when the client states that she
should avoid potato chips, which are high in sodium and low in
nutrients.
,◉ The nurse is discussing risks associated with urinary changes
during pregnancy with a group of nursing students. Which
information should the nurse share with the students?
A. Increased urinary stagnation causes urinary tract infections
B. Increased urinary frequency causes sodium depletion
C. Decreased nocturia causes sodium increases
D. Decreased urine output decreases blood pressure.
Answer: A. Increased urinary stagnation causes urinary tract
infections
Clients will experience urinary changes throughout pregnancy.
Stagnation of urine due to anatomical changes due to the enlarging
uterus placing pressure on the bladder increases maternal risk of
urinary tract infections.
◉ The nurse is caring for a pregnant client who also has a school-age
child. The client is concerned about preparing the child to be an
older sibling. Which should the nurse recognize as the most effective
strategy for helping the older sibling adapt?
A. Show the child where and how to touch the baby
B. Involve the child in bringing the baby home
C. Encourage the child to interact with the baby
,D. Feed the baby separately from the child.
Answer: A. Show the child where and how to touch the baby
The school-age child generally takes a more specific, or clinical
interest in the mother's pregnancy. Showing the child where and
how to touch the baby is one way to help the older child adapt to the
new sibling.
◉ The nurse is examining a client who believes she is pregnant.
Which presumptive sign should the nurse recognize as a possible
indication of pregnancy?
A. Urinary frequency
B. Breast changes
C. Amenorrhea
D. Quickening.
Answer: A. Urinary frequency
Presumptive signs of pregnancy include quickening, amenorrhea,
breast changes, and urinary frequency. The nurse should recognize
that urinary frequency can be a sign of pregnancy because the hCG
hormone increases the blood flow to the kidneys during pregnancy
and the pressure of the enlarging uterus on the bladder during the
first trimester.
, ◉ The nurse has administered Rh immune globulin to a client. The
nurse should report which adverse effect of this medication to the
health care immediately?
A. Muscle pain
B. Insomnia
C. Bradycardia
D. Hypertension.
Answer: D. Hypertension
Rh immune globulin works to suppress the immune response in a
client with Rh negative blood who may have been exposed to Rh
positive blood from a previous Rh positive fetus. The nurse should
assess for hypertension in a client who has been administered Rh
immune globulin, as this is a potentially adverse effect of this
treatment.
◉ Which condition should the nurse recognize as a contraindication
to tocolytic therapy?
A. Cardiac disease
B. Tachypnea
C. Hypotension