A nurse is performing a nutritional assessment for a client during their first prenatal visit at 12 weeks of gestation. Which of the following findings indicates that the client should be referred to a registered dietician?

The client reports that they take a multivitamin daily.

The client reports a 4.5 kg (10 lb) weight gain since their positive pregnancy test.

The client reports that they are nauseous most mornings.

The client reports that they eat prunes to help manage their constipation.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Taking a multivitamin daily is generally recommended during pregnancy to ensure the mother and baby receive necessary nutrients. It does not indicate a need for referral to a dietitian.
Choice B rationale
A weight gain of 4.5 kg (10 lb) since a positive pregnancy test could be a concern depending on the timeframe. If this weight gain occurred rapidly, it could indicate issues such as fluid retention or inadequate nutrition, which would warrant a referral to a dietitian.
Choice C rationale
Nausea, particularly in the morning, is a common symptom of early pregnancy often referred to as “morning sickness”. It does not typically require dietary intervention unless it is severe (hyperemesis gravidarum), leading to weight loss and dehydration.
Choice D rationale
Eating prunes is a natural method to manage constipation, a common issue during pregnancy due to hormonal changes that slow digestion. This choice does not indicate a need for a dietitian referral.

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Correct Answer is A

Explanation

Choice A rationale
Placenta previa is a condition where the placenta partially or completely covers the cervix. Vaginal bleeding, often without pain, is a key symptom and requires immediate medical attention.
Choice B rationale
While a fetal heart rate of 174 bpm is slightly above the normal range (110-160 bpm), it is not the most critical finding in a patient with complete placenta previa.
Choice C rationale
A fundal height of 33 cm at 32 weeks of gestation is within the expected range and does not require immediate follow-up.
Choice D rationale
An abdomen that is soft and non-tender is a normal finding and does not require immediate follow-up.

A. “Heart rate 89/min.”. B. “Cool, clammy skin.”. C. “BP 120/70 mm Hg.”. D. “Moderate lochia serosa.”.

Correct Answer is B

Explanation

Choice A rationale
A heart rate of 89/min is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
Cool, clammy skin can be a sign of shock or other serious conditions such as hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This is a significant finding that should be reported to the provider immediately. Hypoperfusion can lead to inadequate oxygen supply to the body’s organs and tissues, which can result in organ failure and other serious complications. Therefore, any signs of hypoperfusion, including cool, clammy skin, should be reported to the provider immediately for further evaluation and treatment.
Choice C rationale
A blood pressure of 120/70 mm Hg is within the normal range for an adult, and would not typically be a cause for concern.
Choice D rationale
Moderate lochia serosa is a normal finding in a woman who is 3 days postpartum. Lochia serosa is the term for the pink or brownish discharge that occurs after lochia rubra, the bright red discharge that occurs immediately after childbirth. Lochia serosa typically begins about 3- 4 days after delivery and can continue for up to 10 days postpartum.

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A nurse is performing a nutritional assessment for a client during their first prenatal visit at 12 weeks of gestation. Which of the following findings indicates that the client should be referred to a registered dietician?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

“A nurse is caring for a patient who is at 32 weeks of gestation and has complete placenta previa. Which of the following assessment findings requires immediate follow-up?”

Correct Answer is A

Explanation

“A nurse is assessing a patient who is 3 days postpartum. Which of the following findings should the nurse report to the provider?”

Correct Answer is B

Explanation

A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following Questions should the nurse ask to assess the client’s dietary intake?

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A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?

A nurse is caring for a newborn immediately following birth who has a prescription for erythromycin ophthalmic ointment. The guardian refuses the medication. Which action should the nurse take?

A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who is at 33 weeks of gestation. The nurse is assessing the client 24 hours later. How should the nurse interpret the findings?

A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?