A nurse is assessing a client who is in the second trimester of pregnancy and has a BMI within the expected reference range. Which of the following assessment findings indicates that the client will gain weight within the expected reference range?
Weight gain of 0.45 kg (1 lb) per week
Intake of 200 extra calories per day
Intake of 100 extra calories per day
Weight gain of 0.91 kg (2 lb) per week
The Correct Answer is B
Choice A reason: Weight gain of 0.45 kg (1 lb) per week is not within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended weight gain for this client is 0.35 to 0.5 kg (0.8 to 1 lb) per week.
Choice B reason: Intake of 200 extra calories per day is within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended caloric intake for this client is 2200 to 2900 calories per day, which is about 340 to 450 calories more than the pre-pregnancy intake.
Choice C reason: Intake of 100 extra calories per day is not within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended caloric intake for this client is 2200 to 2900 calories per day, which is about 340 to 450 calories more than the pre-pregnancy intake.
Choice D reason: Weight gain of 0.91 kg (2 lb) per week is not within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended weight gain for this client is 0.35 to 0.5 kg (0.8 to 1 lb) per week.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Elastic skin turgor is a sign of adequate hydration and fluid balance. Skin turgor is the ability of the skin to return to its normal shape after being pinched or pulled. When the skin is dehydrated, it loses its elasticity and becomes tented or wrinkled. The nurse should assess the skin turgor on the chest, abdomen, or forehead, and not on the hands or feet, which can be affected by aging or edema.
Choice B reason: Dry mucous membranes are a sign of fluid volume deficit, not fluid volume excess. Mucous membranes are the moist linings of the mouth, nose, eyes, and other body openings. When the body is dehydrated, the mucous membranes become dry, cracked, or sticky. The nurse should assess the mucous membranes for color, moisture, and capillary refill.
Choice C reason: Oliguria is a sign of fluid volume deficit, not fluid volume excess. Oliguria is the production of abnormally small amounts of urine, usually less than 400 mL per day or 30 mL per hour. Oliguria can indicate reduced kidney function, impaired blood flow to the kidneys, or inadequate fluid intake. The nurse should monitor the urine output, color, specific gravity, and presence of blood or protein.
Choice D reason: Tachycardia is a sign of fluid volume deficit, not fluid volume excess. Tachycardia is a rapid heart rate, usually more than 100 beats per minute. Tachycardia can occur when the body is dehydrated, as the heart tries to pump more blood to maintain the blood pressure and perfusion. The nurse should measure the pulse rate, rhythm, quality, and amplitude.
Correct Answer is D
Explanation
Choice D reason: Tuna is a good source of iodine, which is a mineral that is essential for the production of thyroid hormones. A goiter is an enlargement of the thyroid gland that can be caused by iodine deficiency. Eating more iodine-rich foods, such as tuna, can help prevent or treat a goiter.
Choice A reason: Red meat is not a good source of iodine, and it can also be high in saturated fat and cholesterol, which can increase the risk of heart disease and other health problems. Eating more red meat is not advisable for a client who has a goiter.
Choice B reason: Blueberries are not a good source of iodine, and they have no direct effect on the thyroid gland or a goiter. Blueberries are rich in antioxidants and other nutrients, but they are not a specific food choice for a client who has a goiter.
Choice C reason: Bananas are not a good source of iodine, and they have no direct effect on the thyroid gland or a goiter. Bananas are a good source of potassium and fiber, but they are not a specific food choice for a client who has a goiter.
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