A patient at 8 weeks' gestation complains to the nurse, 'I feel sick almost every morning. And I throw up at least two or three times a week.' What is the nurse's best guidance for this patient?

Correct Answer: C

Rationale: The correct answer is C: 'Try eating peanut butter on whole wheat bread right before going to bed.' This recommendation is based on the fact that consuming a small snack high in protein and complex carbohydrates before going to bed can help stabilize blood sugar levels and reduce morning sickness symptoms in pregnant women. Peanut butter provides protein and whole wheat bread provides complex carbohydrates, which can help alleviate nausea and vomiting. Choice A is incorrect because asking about cheese does not address the patient's symptoms or provide any practical guidance for managing morning sickness. Choice B is incorrect because increasing the number of meals may not necessarily alleviate morning sickness and could potentially exacerbate symptoms. Choice D is incorrect because suggesting that eating enough throughout the day will prevent sickness oversimplifies the issue and does not offer targeted advice for managing morning sickness.

Correct Answer: C

Rationale: In the context of maternal and reproductive health clients, teaching the patient perineal care is an independent function of the professional nurse because it involves providing essential education to the patient regarding self-care practices. This intervention empowers the patient to take an active role in their own health management, promoting better outcomes and preventing complications. Administering oral analgesics, requesting diagnostic studies, and providing wound care to a surgical incision are all important nursing interventions, but they typically require a healthcare provider's order or prescription. These actions involve a level of decision-making that goes beyond the independent scope of practice for a nurse. In an educational context, understanding the distinction between independent nursing functions and actions that require provider authorization is crucial for nurses to provide safe and effective care. Nurses must be able to recognize when they can autonomously perform interventions based on their scope of practice and when they need to collaborate with other healthcare team members or seek guidance from a provider. This knowledge ensures patient safety and quality care delivery in maternal and reproductive health settings.

Correct Answer: A

Rationale: In the nursing process, the correct step for determining appropriate interventions for identified nursing diagnoses is Planning, which is option A. Planning occurs after the nurse has completed the assessment and analysis of the client's data to establish nursing diagnoses. In this phase, the nurse collaborates with the client to set goals, prioritize nursing interventions, and develop a comprehensive plan of care tailored to the individual's specific needs. Option B, Evaluation, is incorrect because evaluation is about assessing the outcomes of the interventions to determine if they have been effective in meeting the desired goals. Option C, Assessment, is also incorrect as assessment is the initial phase of the nursing process where data is collected to identify health issues. Option D, Intervention, is not the correct answer as interventions are implemented after the planning phase to address the identified nursing diagnoses based on the formulated care plan. Understanding the nursing process is essential for nurses as it provides a systematic framework to deliver individualized care, promote critical thinking, and improve patient outcomes. By correctly identifying the planning phase as the step for determining interventions, nurses can ensure that their care is evidence-based, holistic, and meets the unique needs of maternal and reproductive health clients.

Correct Answer: D

Rationale: The correct answer is option D: Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM. Rationale: - This intervention promotes maternal well-being by preventing complications like blood clots and enhancing circulation postpartum. - Early ambulation aids in restoring muscle tone, preventing postpartum complications, and promoting overall recovery. - Scheduled ambulation supports a gradual increase in physical activity, which is crucial for postpartum recovery without causing excessive fatigue. Why others are wrong: - Option A (Force fluids as necessary) lacks specificity and may not be appropriate for all maternal clients, as individual fluid needs vary. - Option B (Observe interaction with the infant) is important but not as immediate or crucial for promoting physical recovery postpartum as ambulation. - Option C (Encourage turning, coughing, and deep breathing) is a general nursing intervention but does not specifically address the need for physical activity and mobilization post-delivery. Educational context: Understanding the importance of early ambulation postpartum is vital for nursing students caring for maternal and reproductive health clients. This intervention helps prevent complications, promotes physical recovery, and enhances overall well-being. By implementing scheduled ambulation, nurses can support maternal clients in their postpartum recovery journey effectively.

Correct Answer: D

Rationale: The correct answer is option D) Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of the prescribed analgesic. This expected outcome is appropriate because it reflects a realistic and specific goal for pain management after a vaginal birth. The goal of pain management is to reduce pain to a manageable level, typically around 2 on a scale of 10, which allows the patient to function while still experiencing some discomfort. Option A is incorrect because it sets the goal too low and does not aim for adequate pain relief. Option B is incorrect because it focuses solely on the administration of analgesics without specifying the desired pain level. Option C is incorrect because it assumes complete pain relief within a specific time frame, which may not be realistic or achievable for all patients. In an educational context, understanding how to set appropriate and realistic expected outcomes is crucial for nurses to provide effective care and evaluate the effectiveness of interventions. Setting specific, measurable, achievable, relevant, and time-bound (SMART) goals helps guide patient care and promotes optimal outcomes.