Chapter 8-Clinical Judgment and Next Generation NCLEX Examination Style Question on Nutrition

Nutrition in Pregnancy • The school nurse evaluates a 17-year-old high school senior, who identifies as female, using the pronouns she/her/hers. • During a visit to the clinic, she complained of nausea and “just being so tired.” • The client reports that she wakes up most mornings for the past 2 weeks so sick she can barely get out of bed. • The client states she does not want to eat because she hates to throw up. • Student states she is sleeping 10 to 12 hours a night and wants to nap during the day. • When questioned by the nurse, the client denies having a period for about 2 months and upon further questioning, the nurse determines that it is possible the client is about 11 weeks pregnant. • The pregnancy is confirmed with a urine pregnancy test. • The school nurse refers the client to the high school pregnancy clinic where they complete an assessment and begin prenatal care with the resident nurse midwife. Physical assessment • Physical assessment reveals the client weighs 48.5 kgs (106.7 lb.) and is 65 inches tall. • Her apical pulse is 106, respiratory rate (RR) 18, blood pressure (BP) 106/66, temperature (temp) 98.4, and oxygen saturation (SpO2) is 98% at initial assessment. • Fetal heart rate (FHR) by ultrasound is 144 bpm. • The client denies taking any medications, supplements, alcohol, or tobacco use. • The client states no allergies to food or medications. • The client states this is the first pregnancy and has only been sexually active with one partner and only for a few months. • What is her gravida/para and GTPAL? • G1-T0-P0-A0-L0 • Denies use of any contraception. Background • The client is single, lives with her parents, is a cheerleader, has a GPA of 3.6, and plans to attend community college after graduation in a few months. • The client denies being in a long-term relationship and begs the midwife to “not tell anyone about this pregnancy, not my parents, not anybody!” • Prenatal laboratories are drawn, and a second appointment at the pregnancy clinic is made for 2 weeks to assess nausea and review laboratory work. • Daily prenatal vitamins have been given to the client to begin taking each morning. 1. Highlight or place a checkmark next to the assessment findings that require follow-up by the nurse. • Single 17-year-old female • High school student • Lives with parents • HR 106 • RR 18 • BP 106/66 • Urine pregnancy test • FHR 144 bpm • Medication use • Supplement use • Alcohol/tobacco use • Height • Weight • Contraception • Nausea • Sleep pattern