Nur 160 Test 1
The nurse is assessing a client at 30 weeks' gestation who reports increased constipation. Which
suggestion should the nurse prioritize for this client?
1. Increase intake of meat
2. Reduce iron supplements
2. Take mineral oil
4. Increase fluid intake - correct answer ✔✔4. Increase fluid intake
Explanation:
Increasing fluid content by drinking at least 8 glasses of noncaffeinated beverages helps relieve
constipation in both pregnant and nonpregnant women. Reducing an iron supplement could lead to
anemia; mineral oil can reduce absorption of fat-soluble vitamins. The client should add foods rich in
fiber, which would include grains, vegetables, and fruits (instead of meat).
The nurse is caring for a client who had consistent exposure to lead while pregnant. When the neonate is
born, which focused assessment is essential?
1. Muscle tone
2. Hearing
3. Reflexes
4. Swallowing ability - correct answer ✔✔3. Reflexes
Explanation:
A factor determining the effects of a teratogen is the teratogen's affinity for specific body tissues. Lead
and mercury attack and disable nervous tissue. Assessment of reflexes and cognitive alertness is a
priority. A hearing assessment is completed on most neonates in the nursery before discharge. Screening
does not indicate lead poisoning. Muscle tone and the ability to swallow are not related to lead
poisoning.
,A pregnant client in the second trimester is diagnosed with hyperemesis gravidarum with a 10% weight
loss. The nurse is gathering data to form the foundation of a nutritional nursing care plan. Which way is
best to obtain a nutritional assessment?
1. Outline the meals eaten over the past 7 days
2. Have the client complete an intake and output sheet
3. Complete a 24-hour food and fluid nutritional recall
4. Document food intake over the past 3 days - correct answer ✔✔3. Complete a 24-hour food and fluid
nutritional recall
Explanation:
Hyperemesis gravidarum causes dangerous health effects such as weight loss, dehydration, electrolyte
imbalance, ketonuria, and ketonemia. It is important to complete a nutritional assessment, including
everything that was ingested over the past 24 hours. The assessment includes both foods and fluids
ingested. It is important to understand what was eaten in addition to what is recorded on the intake and
output chart. It is most accurate to have the client recall the intake from the past 24 hours. It is unlikely
that the client would recall all food and fluids ingested over the past 3 or 7 days.
The nurse is concerned that a client is not obtaining enough folic acid. Which test would the nurse
anticipate being used to evaluate the fetus for potential neural tube defects?
1. Triple-marker screen
2. Amniocentesis
3. Doppler flow study
4. Maternal serum alpha-fetoprotein analysis - correct answer ✔✔4. Maternal serum alpha-fetoprotein
analysis
Explanation:
Alpha-fetoprotein is a substance produced by the fetus. AFP enters the maternal circulation by crossing
the placenta. If there is a developmental defect, more AFP escapes into amniotic fluid from the fetus.
The optimal time for AFP screening is 16 to 18 weeks. The triple marker screens for AFP, hCG, and
unconjugated estriol. This screens for neural defects and Down syndrome. The Doppler flow study
evaluates the blood flow, and amniocentesis evaluates the contents of the amniotic fluid looking for
chromosomal defects.
, A client at 29 weeks' gestation tells the nurse she is experiencing aches in her hips and joints. What
would the nurse do next?
1. Have the primary healthcare provider see the client
2. Ask the client if there is a family history of arthritis
3. Tell the client these are normal findings during pregnancy
4. Document these findings in the clients chart - correct answer ✔✔3. Tell the client these are normal
findings during pregnancy
Explanation:
The hormone relaxin causes the smooth muscles, joints, and ligaments of the body to relax. Because of
the production of relaxin during pregnancy, women often experience aches in the pelvic area. The nurse
would explain to the client this is a normal finding of pregnancy and will resolve. The nurse should
document this in the chart, but it is not priority over educating the client.
The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32 weeks' gestation.
Which action would be most appropriate?
1. Ask another nurse to assess the heart
2. Inquire if the patient has chest pain
3. Document this and continue to monitor the murmur at future visits
4. Refer her for cardiac catheterization - correct answer ✔✔3. Document this and continue to monitor
the murmur at future visits
Explanation:
Due to the increased blood volume that occurs with pregnancy, soft systolic murmurs may be heard and
are considered normal
To prevent exposure to hepatitis A virus, the nurse teaches the pregnant client to avoid which food?
The nurse is assessing a client at 30 weeks' gestation who reports increased constipation. Which
suggestion should the nurse prioritize for this client?
1. Increase intake of meat
2. Reduce iron supplements
2. Take mineral oil
4. Increase fluid intake - correct answer ✔✔4. Increase fluid intake
Explanation:
Increasing fluid content by drinking at least 8 glasses of noncaffeinated beverages helps relieve
constipation in both pregnant and nonpregnant women. Reducing an iron supplement could lead to
anemia; mineral oil can reduce absorption of fat-soluble vitamins. The client should add foods rich in
fiber, which would include grains, vegetables, and fruits (instead of meat).
The nurse is caring for a client who had consistent exposure to lead while pregnant. When the neonate is
born, which focused assessment is essential?
1. Muscle tone
2. Hearing
3. Reflexes
4. Swallowing ability - correct answer ✔✔3. Reflexes
Explanation:
A factor determining the effects of a teratogen is the teratogen's affinity for specific body tissues. Lead
and mercury attack and disable nervous tissue. Assessment of reflexes and cognitive alertness is a
priority. A hearing assessment is completed on most neonates in the nursery before discharge. Screening
does not indicate lead poisoning. Muscle tone and the ability to swallow are not related to lead
poisoning.
,A pregnant client in the second trimester is diagnosed with hyperemesis gravidarum with a 10% weight
loss. The nurse is gathering data to form the foundation of a nutritional nursing care plan. Which way is
best to obtain a nutritional assessment?
1. Outline the meals eaten over the past 7 days
2. Have the client complete an intake and output sheet
3. Complete a 24-hour food and fluid nutritional recall
4. Document food intake over the past 3 days - correct answer ✔✔3. Complete a 24-hour food and fluid
nutritional recall
Explanation:
Hyperemesis gravidarum causes dangerous health effects such as weight loss, dehydration, electrolyte
imbalance, ketonuria, and ketonemia. It is important to complete a nutritional assessment, including
everything that was ingested over the past 24 hours. The assessment includes both foods and fluids
ingested. It is important to understand what was eaten in addition to what is recorded on the intake and
output chart. It is most accurate to have the client recall the intake from the past 24 hours. It is unlikely
that the client would recall all food and fluids ingested over the past 3 or 7 days.
The nurse is concerned that a client is not obtaining enough folic acid. Which test would the nurse
anticipate being used to evaluate the fetus for potential neural tube defects?
1. Triple-marker screen
2. Amniocentesis
3. Doppler flow study
4. Maternal serum alpha-fetoprotein analysis - correct answer ✔✔4. Maternal serum alpha-fetoprotein
analysis
Explanation:
Alpha-fetoprotein is a substance produced by the fetus. AFP enters the maternal circulation by crossing
the placenta. If there is a developmental defect, more AFP escapes into amniotic fluid from the fetus.
The optimal time for AFP screening is 16 to 18 weeks. The triple marker screens for AFP, hCG, and
unconjugated estriol. This screens for neural defects and Down syndrome. The Doppler flow study
evaluates the blood flow, and amniocentesis evaluates the contents of the amniotic fluid looking for
chromosomal defects.
, A client at 29 weeks' gestation tells the nurse she is experiencing aches in her hips and joints. What
would the nurse do next?
1. Have the primary healthcare provider see the client
2. Ask the client if there is a family history of arthritis
3. Tell the client these are normal findings during pregnancy
4. Document these findings in the clients chart - correct answer ✔✔3. Tell the client these are normal
findings during pregnancy
Explanation:
The hormone relaxin causes the smooth muscles, joints, and ligaments of the body to relax. Because of
the production of relaxin during pregnancy, women often experience aches in the pelvic area. The nurse
would explain to the client this is a normal finding of pregnancy and will resolve. The nurse should
document this in the chart, but it is not priority over educating the client.
The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32 weeks' gestation.
Which action would be most appropriate?
1. Ask another nurse to assess the heart
2. Inquire if the patient has chest pain
3. Document this and continue to monitor the murmur at future visits
4. Refer her for cardiac catheterization - correct answer ✔✔3. Document this and continue to monitor
the murmur at future visits
Explanation:
Due to the increased blood volume that occurs with pregnancy, soft systolic murmurs may be heard and
are considered normal
To prevent exposure to hepatitis A virus, the nurse teaches the pregnant client to avoid which food?
