A nurse is caring for a client at the first prenatal visit who has an ideal body weight for her height. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?

"A gain of about 1 pound per week is recommended for you."

"A gain of about about 15 to 25 pounds is recommended for you."

"A gain of about 25 to 35 pounds is recommended for you."

"A gain of about 30 to 40 pounds is recommended for you."

Answer and Explanation

The Correct Answer is C

A. "A gain of about 1 pound per week is recommended for you.": Although gaining approximately 1 pound per week during the second and third trimesters is typical, this does not address the total recommended weight gain. A more complete answer should reflect the full pregnancy range.

B. "A gain of about 15 to 25 pounds is recommended for you.": This weight gain range is appropriate for someone who is overweight before pregnancy. For individuals with an ideal pre-pregnancy weight, a higher range is recommended to support fetal growth and maternal health.

C. "A gain of about 25 to 35 pounds is recommended for you.": This is the recommended total weight gain for a client who starts pregnancy at an ideal body weight. It supports healthy fetal development, amniotic fluid volume, placental growth, and maternal tissue changes.

D. "A gain of about 30 to 40 pounds is recommended for you.": This range is more appropriate for underweight clients, who need additional weight to support pregnancy needs. For someone with an ideal weight, it exceeds what is generally advised.

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Correct Answer is D

Explanation

A. 1+ pitting sacral edema: Mild pitting edema is a common clinical feature of preeclampsia, especially in the lower extremities or sacral area due to fluid retention. This finding aligns with expected symptoms and is not inconsistent with the diagnosis.

B. 3+ protein in the urine: Significant proteinuria (≥300 mg/24 hr or ≥1+ on dipstick) is a key diagnostic criterion for preeclampsia. A 3+ result reflects marked protein loss and supports the diagnosis, not contradicts it.

C. Blood pressure 148/98 mm Hg: A systolic pressure ≥140 mm Hg or diastolic ≥90 mm Hg on two readings at least 4 hours apart confirms hypertension in pregnancy. This value fits the diagnostic criteria for preeclampsia.

D. Deep tendon reflexes of +1: Clients with preeclampsia often exhibit hyperreflexia (+3 or +4) due to CNS irritability. A reflex score of +1 is diminished and inconsistent with the expected heightened neuromuscular activity seen in preeclampsia.

A. Malaria B. Trichomoniasis C. HIV D. Rubella

Correct Answer is D

Explanation

A. Malaria: Although malaria can cross the placenta and cause complications like low birth weight or miscarriage, it is not classified under the TORCH group of infections. TORCH specifically includes infections known to cause congenital abnormalities.

B. Trichomoniasis: Trichomoniasis is a sexually transmitted infection that may cause preterm labor but is not part of the TORCH group. It does not typically result in congenital anomalies in the fetus when transmitted during pregnancy.

C. HIV: HIV can be transmitted from mother to fetus, but it is not included in the TORCH acronym. While HIV poses serious risks, it is managed differently and is not primarily linked to structural congenital defects.

D. Rubella: Rubella is a key TORCH infection and is highly teratogenic, especially in the first trimester. It can lead to congenital rubella syndrome, causing deafness, cataracts, heart defects, and developmental delays in the fetus.

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A nurse is caring for a client at the first prenatal visit who has an ideal body weight for her height. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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