Which nursing intervention is most appropriate when caring for a pregnant client experiencing mild morning sickness?
Encourage the client to eat three large meals a day.
Advise the client to drink large amounts of water with meals.
Suggest eating dry crackers before getting out of bed in the morning.
Recommend a high-fat diet to increase caloric intake.
The Correct Answer is C
Choice A rationale
Eating three large meals is contraindicated because it increases gastric volume and pressure, which can exacerbate nausea and trigger vomiting during pregnancy. Physiological changes in the first trimester involve rising human chorionic gonadotropin levels that slow gastric emptying. Consuming larger quantities of food at once leads to excessive stomach distention, further delaying the transit of contents and increasing the likelihood of gastroesophageal reflux and morning sickness symptoms.
Choice B rationale
Consuming significant amounts of fluid during meals can lead to overdistention of the stomach and a feeling of excessive fullness, which often triggers the gag reflex in pregnant clients. It is scientifically more effective to separate liquid and solid intake to avoid overloading the digestive system. Keeping fluids between meals ensures hydration without increasing the gastric pressure that typically accompanies the simultaneous intake of solids and liquids, thereby reducing the frequency of emetic episodes.
Choice C rationale
Dry carbohydrates like crackers are effective because they help absorb excess gastric acid and stabilize blood glucose levels before the client changes position. In the morning, an empty stomach and low blood sugar can trigger the chemoreceptor trigger zone, leading to nausea. By consuming bland, dry starches before rising, the client prevents the sudden shift in gastric contents and metabolic state that occurs with movement, providing a buffer against pregnancy-induced emesis.
Choice D rationale
High-fat diets are difficult to digest and significantly delay gastric emptying time, which is already slowed by the hormone progesterone. Fatty foods relax the lower esophageal sphincter, allowing gastric acid to reflux and irritate the esophageal lining, which intensely worsens nausea. Promoting a diet high in simple carbohydrates and proteins is scientifically preferred, as these are processed more efficiently by the gastrointestinal tract and do not contribute to the greasy residue that triggers nausea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Choice A rationale:
Ultrasonography is a high-tech diagnostic tool that uses high-frequency sound waves to visualize the fetus, placenta, and amniotic fluid. While it is non-invasive, it requires specialized equipment and a trained technician or physician to perform and interpret the results. It is not a method the patient can use herself at home. It is primarily used for assessing growth, anatomy, and checking the volume of the amniotic fluid.
Choice B rationale
Amniocentesis is an invasive procedure involving the withdrawal of amniotic fluid via a needle inserted through the abdominal wall. It is used to detect genetic abnormalities or assess fetal lung maturity. This procedure carries risks such as infection or miscarriage and must be performed by a specialist under ultrasound guidance. It is considered a high-tech medical intervention and is never a self-monitoring method for a pregnant patient.
Choice C rationale
A biophysical profile is a comprehensive assessment of fetal well-being that combines a non-stress test with ultrasound evaluation. It scores five variables: fetal breathing, movements, tone, amniotic fluid volume, and heart rate reactivity. This requires clinical equipment and professional expertise to conduct and interpret the total score. Because it relies on technology and clinical observation, it does not meet the criteria for a low-tech, patient-led monitoring method.
Choice D rationale
Counting fetal kicks, also known as the Cardiff count-to-ten method, is a simple, low-tech, and cost-effective way for a mother to monitor fetal well-being. Maternal perception of fetal movement is a direct indicator of fetal oxygenation and central nervous system integrity. Generally, a healthy fetus should move at least 10 times within two hours. A decrease in movement requires immediate clinical follow-up to rule out fetal distress or hypoxia.
Correct Answer is A
Explanation
Choice A rationale
For a 17-year-old adolescent who is non-verbal following a suicide attempt, providing a journal is an evidence-based intervention to facilitate expression. Adolescence is characterized by the need for autonomy and privacy. Writing allows the patient to process intense emotions and traumatic thoughts without the immediate pressure of face-to-face verbal interaction. This method respects their current psychological defense mechanisms while still providing a therapeutic outlet for the heavy internal burden they are currently carrying.
Choice B rationale
Using phrases that begin with you can often be perceived as accusatory or confrontational, especially by an adolescent in a mental health crisis. In therapeutic communication, I statements are preferred to express observations without making the patient feel defensive. For a patient who has attempted suicide, you statements might inadvertently increase feelings of guilt or shame. The goal is to reduce pressure on the patient, and direct you-focused language can actually hinder the development of a therapeutic alliance.
Choice C rationale
Directly asking a patient how they feel when they are currently refusing to speak is often ineffective and can be perceived as intrusive. This approach does not account for the patient's current state of psychological withdrawal or elective mutism. Adolescents often shut down when they feel pressured to perform or explain themselves. Therapeutic silence or offering alternative forms of communication, such as writing, is more effective than demanding verbalization during the acute phase of post-suicide attempt recovery.
Choice D rationale
Providing toys and games is developmentally inappropriate for a 17-year-old patient. According to Erikson's stages of development, this patient is in the stage of Identity vs. Role Confusion. Treating a near-adult with pediatric play items can be demeaning and may further alienate them from the nursing staff. While some forms of recreational therapy are useful, they must be age-appropriate. Using toys for an adolescent ignores their cognitive maturity and the gravity of their clinical situation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.