A client in the first trimester reports nausea. What dietary recommendation should the nurse make?

Correct Answer: A

Rationale: In the first trimester of pregnancy, many women experience nausea, commonly known as morning sickness. The correct dietary recommendation for a client experiencing nausea in the first trimester is to eat dry crackers before getting out of bed (Option A). This suggestion is appropriate because dry crackers can help alleviate nausea by absorbing stomach acids and providing a bland, starchy food source that is easy on the stomach. Option B, avoiding eating throughout the day, is incorrect because it can lead to low blood sugar levels, exacerbating nausea. Option C, increasing intake of spicy foods, is also incorrect as spicy foods can further irritate the stomach and worsen nausea. Option D, consuming large, infrequent meals, is not recommended as it can overwhelm the digestive system and trigger or worsen nausea in pregnant women. Educationally, it is important for nurses to understand the dietary recommendations for common discomforts during pregnancy to provide appropriate care and support to pregnant clients. By knowing the rationale behind each dietary recommendation, nurses can effectively educate their clients on how to manage symptoms and promote their well-being during pregnancy.

Correct Answer: C

Rationale: In a pregnant client with gestational hypertension, the primary complication to prevent is eclampsia. Eclampsia is a serious condition characterized by the development of seizures in a woman with pre-eclampsia, a condition of high blood pressure during pregnancy. Eclampsia can lead to life-threatening complications for both the mother and the fetus if not managed promptly. Preterm labor (option A) is not the primary complication to prevent in a pregnant client with gestational hypertension. While gestational hypertension can increase the risk of preterm labor, the immediate concern is preventing eclampsia. Placenta previa (option B) is a condition where the placenta partially or completely covers the cervix, leading to bleeding during pregnancy. While placenta previa is a concern in pregnancy, it is not directly associated with gestational hypertension. Abruptio placentae (option D) is the premature separation of the placenta from the uterus before delivery. While gestational hypertension can increase the risk of abruptio placentae, the primary focus in this scenario is preventing eclampsia due to its immediate life-threatening nature. Educationally, understanding the complications associated with gestational hypertension is crucial for nurses caring for pregnant clients. Recognizing the signs and symptoms of eclampsia and implementing appropriate interventions can significantly impact maternal and fetal outcomes. Early detection and management of gestational hypertension can help prevent complications such as eclampsia and improve overall pregnancy outcomes.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Place the client in a left lateral position. This intervention is crucial because the pregnant client is experiencing dizziness and lightheadedness when lying on her back, indicating a potential issue with supine hypotension syndrome. By positioning the client on her left side, pressure on the inferior vena cava is relieved, improving blood flow to the placenta and preventing further episodes of dizziness and lightheadedness. Option A) Administer oxygen via face mask is incorrect because the client's symptoms are not indicative of hypoxia. Oxygen administration would not address the underlying issue of supine hypotension syndrome. Option C) Encourage deep breathing exercises is incorrect as well. While deep breathing exercises can be beneficial in certain situations, they would not directly address the client's symptoms related to positional changes causing decreased blood flow. Option D) Increase IV fluid rate is also incorrect. While maintaining hydration is important during pregnancy, increasing IV fluids would not be the priority intervention in this case. Positioning the client correctly to alleviate supine hypotension syndrome takes precedence. Educationally, understanding the physiological changes that occur during pregnancy, such as the impact of supine positioning on blood flow, is crucial for nurses caring for pregnant clients. Recognizing and effectively managing conditions like supine hypotension syndrome can prevent complications and ensure optimal maternal and fetal outcomes.

Correct Answer: B

Rationale: In the context of monitoring a client in active labor, a fetal heart rate of 90 beats/minute (option B) indicates the need for immediate intervention. A fetal heart rate of 90 bpm is considered bradycardia, which can be a sign of fetal distress and requires prompt evaluation and intervention to prevent adverse outcomes. Bradycardia in labor can be caused by various factors such as umbilical cord compression, maternal hypotension, or fetal hypoxia. Contractions every 2-3 minutes (option A) are a normal part of active labor and do not necessarily indicate a need for immediate intervention unless they are too frequent or prolonged. Cervical dilation of 6 cm (option C) is also a normal progression in labor and indicates that the client is progressing towards delivery. Client reports of back pain (option D) are common during labor and may not always indicate a need for immediate intervention unless it is severe or associated with other concerning symptoms. In an educational context, understanding the significance of fetal heart rate monitoring in labor is crucial for nurses and healthcare providers caring for laboring clients. It is essential to recognize abnormal patterns and take timely action to ensure the well-being of both the mother and the baby. This question reinforces the importance of continuous assessment and prompt intervention in labor and delivery settings.

Correct Answer: D

Rationale: In the context of caring for a postpartum client with a perineal laceration, offering an ice pack for the perineum is the most appropriate comfort measure. The rationale behind this choice is based on the principle of vasoconstriction that occurs with the application of cold therapy. Ice packs help to reduce swelling, inflammation, and pain by constricting blood vessels, thereby decreasing blood flow to the area and numbing the nerves, which can provide relief to the perineal region. Encouraging warm sitz baths (Option A) can be beneficial for promoting healing and providing comfort in certain situations, but in the case of a perineal laceration, cold therapy is generally more effective initially due to its vasoconstrictive properties. Applying warm compresses to the perineum (Option B) and providing a heating pad for the lower abdomen (Option C) can be soothing in some instances, but they can potentially increase blood flow to the area, leading to more swelling and discomfort in the case of a perineal laceration. In an educational context, understanding the rationale behind choosing the most appropriate comfort measure for a specific situation is crucial for providing safe and effective care to postpartum clients with perineal lacerations. Nurses need to have a solid foundation in the principles of thermal therapy and its effects on the body to make informed decisions regarding comfort measures for their patients.