Ch 13: The Nursing Role in Promoting Nutritional Health During Pregnancy

c) Serum iron level Pg. 297 Pregnant clients who crave ice often have an iron deficiency. A low serum iron level needs to be checked. The client's electrolyte values are not associated with cravings for ice.

12. A pregnant client reports chewing on ice throughout the day. Which laboratory value would the nurse evaluate? a) Serum glucose level b) Serum sodium level c) Serum iron level d) Serum potassium level

b) Dark, leafy green vegetables Pg. 303 Dark leafy green vegetables are a source of calcium. Red and orange vegetables contain a variety of vitamins, bread and rice contain carbohydrates, and meat and fish contain protein, but none of these foods are a good source of calcium.

22. A nurse is providing education to a client who is 8 weeks' pregnant. The client stated she does not like milk. What is a source of calcium that the nurse can recommend to the client? a) White bread and rice b) Dark, leafy green vegetables c) Meat, poultry, and fish d) Deep red or orange vegetables

d) Ask the client to recall what was eaten and drank in the last 24 hours Pg. 292-293 The 24-hour recall is the best way to assess a client's dietary practices. It provides the actual eaten foods for a basis of discussion. Asking the client to list favorite foods (or if there is an ethnic style of cooking) would have to be followed by how often those foods are eaten. Assessing foods the client would like to have in the diet can be the start of instruction on obtaining and preparing nutritious foods. These foods are not currently part of (or only a small part of) the client's diet.

10. When interviewing a pregnant client, how can the nurse best assess the client's dietary intake? a) Ask the client what foods are desired so as to include more of these in the diet b) Ask the client to list favorite foods and how often they are eaten c) Ask the client if there is an ethnic style of cooking in the home d) Ask the client to recall what was eaten and drank in the last 24 hours

c) "I am glad I can have my two cups of coffee in the morning again" Pg. 291 Breastfeeding mothers should avoid caffeine because it delays iron absorption and passes through the milk and can slow infant weight gain. Similarly, spicy foods pass into the breastmilk and can affect the baby. Breastfeeding mothers need added calories and fluids.

11. The nurse is conducting a teaching session for breastfeeding mothers. Which statement by a mother requires further clarification by the nurse? a) "I will drink a large glass of water each time I nurse my baby" b) "I will continue to take a prenatal multivitamin as long as I am breastfeeding" c) "I am glad I can have my two cups of coffee in the morning again" d) "I will continue to add about 300 calories per day to my diet"

c) "In addition to protein from dairy, eat complementary proteins such as beans and rice together, or beans and wheat together" Pg. 302 It is important for the nurse to understand the vegetarian diet because nutrition is an important teaching point for intrapartal woman. Women who are vegetarian usually do not eat fish and some do not eat eggs. Most proteins from nonanimal sources are incomplete proteins that need to be combined with other nonanimal proteins to become complete proteins. Client education on how to eat complementary proteins such as beans and rice, legumes and rice, or beans and wheat can help vegetarians increase protein in the diet. It is not realistic for the client to eat tofu at every meal.

13. A client is 25 weeks' pregnant. The client explains that she is having difficulty getting an adequate amount of protein into the diet because she is a vegetarian. How can the nurse counsel this client? a) "Because you are a vegetarian, try to eat at least 5 servings of fish or seafood per week" b) "Eat more leafy greens such as spinach and romaine lettuce and more vegetable oils, almonds, and avocados" c) "In addition to protein from dairy, eat complementary proteins such as beans and rice together, or beans and wheat together" d) "Because you do not eat meats, eat the equivalent of tofu with each meal"

b) Eat small meals frequently rather than large meals Pg. 298 Pyrosis (heartburn) is a burning sensation along the esophagus caused by regurgitation of gastric contents into the lower esophagus. In pregnancy, it may accompany early nausea but also persist beyond the resolution of nausea and even increase in severity as pregnancy advances. Common suggestions to help prevent reflux into the esophagus and relieve pain are as follows: eat small meals frequently rather than large meals; sleep on the left side with two pillows to elevate the upper torso; do not lie down immediately after eating—try to wait at least 2 hours; avoid fatty and fried foods, coffee, carbonated beverages, tomato products, and citrus juices.

14. A woman in her third trimester is suffering from heartburn. What should the nurse advise her to do? a) Consume tomato products and citrus juices regularly b) Eat small meals frequently rather than large meals c) Lie down immediately after eating d) Sleep on the back with the feet elevated

d) 150 to 160 pounds (68.2 to 72.7 kg) Pg. 285-286 A simple rule of thumb for a client of normal pre-pregnant weight is weight gain should be about 10 pounds (4.5 kg) by 20 weeks' gestation and about 1 lb (0.45 kg) per week for the remaining 20 weeks, for a total of 25 to 35 pounds (11.4 to 15.9 kg) during the pregnancy. With the client's weight being 125 pounds (56.8 kg), her estimated weight is 150 to 160 pounds (68.2 to 72.7 kg) if weight gain follows this trend. Gaining 10 to 15 pounds (4.5 to 6.8 kg) is not enough weight gained. Gaining over 160 pounds (72.7 kg) exceeds anticipated healthy weight gain.

16. A newly pregnant client weighing 125 pounds (56.8 kg) is concerned about excessive weight gain during her pregnancy. She states, "I don't want to get fat!" The nurse is correct to instruct that by birth, the woman's weight should be within which range? a) 180 to 190 pounds (81.8 to 86.4 kg) b) 170 to 180 pounds (77.3 to 81.8 kg) c) 135 to 140 pounds (61.4 to 63.6 kg) d) 150 to 160 pounds (68.2 to 72.7 kg)

d) More consistent regulation of glucose and insulin Pg. 288 Advise women to obtain their carbohydrate calories from complex carbohydrates (cereals and grains) rather than simple carbohydrates (sugar and fruits) because complex carbohydrates are more slowly digested. Doing so will help regulate glucose and insulin levels more consistently. All carbohydrates contain roughly the same amount of calories per gram (4 kcal/g). Carbohydrates of any kind are not a significant source of fatty acids.

23. A nurse counsels a pregnant woman regarding her recommended daily allowance of calories. She advises her to obtain her carbohydrate calories from complex carbohydrates rather than simple carbohydrates. What is the best rationale for this guidance? a) Faster digestion of complex than simple carbohydrates b) Greater fatty acid content c) Provision of a greater amount of calories per gram d) More consistent regulation of glucose and insulin

a) Complete a 24-hour food and fluid nutritional recall Pg. 304 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.

25. 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? a) Complete a 24-hour food and fluid nutritional recall b) Have the client complete an intake and output sheet c) Document food intake over the past 3 days d) Outline the meals eaten over the past 7 days

a) Severe dehydration resulting in hypoperfusion of the placenta Pg. 304 With severe dehydration there is hypoperfusion to the placenta, and preterm labor may be initiated. Ketonuria impacts the fetus' neurologic development but does not initiate preterm labor. Medications used to control nausea and vomiting do not induce labor.

26. Untreated hyperemesis can lead to preterm birth. What is the cause of the preterm birth? a) Severe dehydration resulting in hypoperfusion of the placenta b) Class B drugs used to control the vomiting resulting in uterine contractions c) Ketonuria resulting in neurologic changes in the fetus d) Poor nutrient intake resulting in poor fetal growth

c) Fats are essential during pregnancy, and vegetable oils are a good source Pg. 289 Omega-3 fatty acids, particularly linoleic acid, are fats that are essential for new cell growth but cannot be manufactured by the body. Vegetable oils such as safflower, corn, olive, peanut, and cottonseed, fatty fish, omega-3 infused eggs, and omega-3 infused spreads are all good sources. Pregnant women should ingest between 200 and 300 mg daily. Because some fish may be contaminated by mercury, alert women that the American Pregnancy Association (APA) recommends that marlin, orange roughy, tilefish, swordfish, shark, king mackerel, and bigeye and ahi tuna should be avoided during pregnancy.

29. A woman relates to the nurse that she understands that dietary fat is bad for her and that she should avoid it during pregnancy. How should the nurse respond? a) Fats are not essential during pregnancy and thus are optional b) Fats are essential during pregnancy, and fish such as marlin and orange roughy are good sources c) Fats are essential during pregnancy, and vegetable oils are a good source d) Fats should be avoided during pregnancy

b) "Alter your breakfast to light foods and have small, frequent meals throughout the day" Pg. 297 Nausea peaks at 9 weeks and usually disappears by 14 weeks. A pregnant client should try to always keep something small in the stomach, opposed to a full meal, to avoid hypoglycemia which can exacerbate the nausea. Small or light and frequent meals are encouraged as they are most often able to be tolerated. Although it is good that the client is not vomiting, nausea can effect nutritional status, which is as much of a concern as electrolyte imbalance.

3. A 33-year-old multipara is 6 weeks' pregnant. The client states having always felt nauseous in the early part of pregnancy and is concerned about dietary intake at the beginning of this pregnancy because it seems the nauseous feeling is beginning earlier. How will the nurse counsel this client? a) "If you continue to feel nauseous, eat one full meal per day and sip on water as tolerated" b) "Alter your breakfast to light foods and have small, frequent meals throughout the day" c) "As long as you do not develop any vomiting, your electrolytes will be maintained" d) "Nausea peaks at 6 weeks. Symptoms are probably at their peak"

d) Enacting a 24-hour nutrition recall Pg. 284 Nutritional status is an important assessment when caring for a pregnant client. Although all of the answers refer to interventions that the nurse should include in the assessment, the 24-hour nutrition recall is the best single method for assessing the client's nutritional intake. Depending upon the pre-pregnancy weight or BMI of the client, they may not be an indicator of current nutritional status. Food cravings are part of the nutritional recall.

4. A nurse is assessing a client's nutritional intake during pregnancy. What method will the nurse use to accomplish this? a) Calculating the client's body mass index (BMI) b) Weighing the client c) Having the client describe food cravings d) Enacting a 24-hour nutrition recall

a) Continue to gain approximately 1 lb (.45 kg) per week during this pregnancy Pg. 285 Expected weight gain is 1.5 lb (0.68 kg) per month in the first trimester and 1 lb (.45 kg) per week for the second and third trimester. This client needs to continue to gain 1 lb (.45 kg) per week. Restricting weight gain near the end of pregnancy can negatively impact fetal growth.

8. At 32 weeks' gestation a client with a BMI of 23 has gained 24 lb (11 kg). What is the nurse's recommendation for weight gain for the remainder of this pregnancy? a) Continue to gain approximately 1 lb (.45 kg) per week during this pregnancy b) Watch the diet so no additional weight is gained during this pregnancy c) Increase weight gain to 1.5 lb (0.68 kg) per week during this pregnancy d) Limit weight gain to less than 5 lb (2 kg) for the remainder of this pregnancy

b) Eat dry crackers or toast before rising Pg. 297 The nurse should recommend the client eat dry crackers or toast before rising to prevent nausea and vomiting in the morning. Drinking plenty of fluids at bedtime could cause nocturia. Foods such as cheese should be avoided to prevent constipation. Spicy foods could cause heartburn.

9. A client in the first trimester reports having nausea and vomiting, especially in the morning. Which instruction would be most appropriate to help prevent or reduce the client's compliant? a) Avoid eating spicy food b) Eat dry crackers or toast before rising c) Drink plenty of fluids at bedtime d) Avoid foods such as cheese

d) Walk for 30 minutes 5 days a week Pg. 287 For a sedentary client a walking program is an appropriate goal. Dieting/weight reduction is never recommended during pregnancy. A daily aerobic or weight lifting program are not appropriate goals for a sedentary client with a high BMI.

1. The nurse teaches a sedentary pregnant client with a BMI of 35 about the importance of healthy lifestyle during pregnancy. Which goal would be appropriate for this client? a) Begin lifting weights for 30 minutes per day b) Adhere to a weight reduction diet c) Participate in a daily aerobic dance program d) Walk for 30 minutes 5 days a week

d) Citrus juice Pg. 291 The citric acid in juice enhances absorption of iron in the GI tract. Ice water and tea do not enhance iron absorption, and milk can inhibit iron absorption.

15. The nurse is teaching about an iron supplement that the client is going to take every day. The nurse teaches the client to take the iron supplement with which type of fluid? a) Ice water b) Hot tea c) Low-fat milk d) Citrus juice

c) 50% of women report pyrosis at some point in pregnancy Pg. 298 Fifty percent of pregnant women have nausea and vomiting. Only 1 in 200 or 1 in 300 women develop hyperemesis gravidarum (severe nausea and vomiting). Hypercholesterolemia predisposes women to development of cholelithiasis (gallstones).

19. Which of the following is true regarding problems that commonly affect nutritional health in pregnancy? a) 15% of women develop hyperemesis gravidarum b) Although nausea is very common in pregnancy, vomiting is rare and is a concern only in women with hyperemesis gravidarum c) 50% of women report pyrosis at some point in pregnancy d) Women who have hyperemesis gravidarum are at highest risk for developing cholelithiasis

b) A list of foods that contain calcium Pg. 296 Because dairy products often are not a part of the Japanese American diet, it can be helpful to point out alternative sources of calcium. A Japanese American diet is typically high in sodium and low in fat but rich in nutrients. Meat portions tend to be small, but fish is often consumed; therefore, the diet is adequate in omega-3 fatty acids.

2. When counseling a Japanese American about nutrition and diet in pregnancy, it would be important to include: a) Alternatives to foods high in monounsaturated fats b) A list of foods that contain calcium c) A list of foods that are high in omega-3 fatty acids d) Healthy ways to increase salt intake

d) Blood glucose Pg. 304 The blood glucose level needs to be tested. If it is elevated, it suggests the concentration of glucose is too high for the body to metabolize.

27. A client with hyperemesis gravidarum is started on total parenteral nutrition (TPN). What parameter does the nurse need to assess at least twice a day? a) Potassium level b) Hemoglobin and hematocrit c) Blood ketones d) Blood glucose

b) Eggs Pg. 302 Lacto-ovo-vegetarians eat no animal flesh or fish, but they do eat dairy products, so eggs are a source of protein. Brown rice is not a source of protein.

28. When counseling a lacto-ovo-vegetarian client, the nurse would recommend including which source of protein in the diet during pregnancy? a) Brown rice b) Eggs c) Chicken d) Fish

b) "I need to gain 25 to 35 pounds (11 to 16 kg) during this pregnancy" Pg. 285-286 A prepregnant BMI of 23 is in the normal category, and this client needs to gain 25 to 35 lbs (11 to 16 kg) during this pregnancy. Lower weight gain would be recommended for women with a BMI of over 25.

33. The nurse is completing the teaching for a newly pregnant client with a BMI of 23. Which statement by the client indicates an understanding of weight gain during this pregnancy? a) "I need to gain less than 25 pounds (11 kg) during this pregnancy" b) "I need to gain 25 to 35 pounds (11 to 16 kg) during this pregnancy" c) "I need to gain 1 pound (0.45 kg) per week throughout this pregnancy" d) "I need to gain 0.5 pounds (0.23 kg) per week during this pregnancy"

b) The serum iron level Pg. 297 The nurse is correct to assess for other indications for pica. Iron deficiency was thought to be a risk factor for pica but iron deficiency may be a consequence. Eating clay or soil may displace the intake of iron-rich foods from the diet and may interfere with iron absorption. A serum iron level to assess is most helpful. Weight gain and skin turgor are not associated with pica. Pulse oximetry level is not as indicative.

7. The nurse is caring for a client with a history of pica. After obtaining a nutritional assessment, which other assessment data would be helpful for the nurse to obtain? a) The client's weight gain b) The serum iron level c) The client's skin turgor d) The pulse oximeter reading

b) Taking a B12 supplement Pg. 289 B12 is found almost exclusively in animal proteins and therefore is absent in the vegetarian diet. Fiber and dark green vegetables are needed. Vitamins A and C are not protein based and are found in a vegetarian diet.

17. The nurse educates the vegetarian client about which nutritional need during pregnancy? a) Avoiding high intake of dark green vegetables b) Taking a B12 supplement c) Limiting the intake of fiber d) Supplementing the diet with vitamins A and C

d) Limiting intake of heavy, greasy foods Pg. 297 Nausea and vomiting can be lessened by limiting intake of fatty and greasy foods and eating small frequent meals every 2 to 3 hours. Other interventions include eating carbohydrate foods such as dry crackers, Melba toast, dry cereal, or hard candy before getting out of bed in the morning. Avoid drinking liquids with meals; avoid coffee, tea, and spicy foods; and eliminate individual food intolerances. Drinking liquids, increasing fluid intake, and limiting carbohydrate intake does not lessen nausea and vomiting.

18. Nausea and vomiting are common reports during pregnancy. What nutritional action can be used to lessen nausea and vomiting? a) Increasing fluid intake b) Limiting carbohydrate intake c) Drinking liquids with meals d) Limiting intake of heavy, greasy foods

b) "Usually after 12 weeks, when the placenta starts managing the production of progesterone, morning sickness ends" Pg. 295 The nurse commonly instructs on morning sickness as it is a common discomfort of early pregnancy. By 12 weeks' gestation, the placenta has grown sufficiently to take over production of progesterone and the corpus luteum is absorbed. Most clients who have morning sickness start feeling better once the placenta takes over. It is uncommon to have morning sickness late in pregnancy or throughout the entire pregnancy. Estrogen is maintained throughout pregnancy and does not become depleted.

20. A pregnant client states, "I am only 6 weeks' pregnant and I have been absent from work five times due to morning sickness. Most days, I am just able to get there. When is it going to stop?" What is the appropriate response by the nurse? a) "Morning sickness is going to occur for the first 16 weeks of the pregnancy, until estrogen stores are depleted" b) "Usually after 12 weeks, when the placenta starts managing the production of progesterone, morning sickness ends" c) "Since you are so sensitive to hormonal levels of pregnancy, you will have morning sickness your entire pregnancy" d) "Morning sickness is part of pregnancy for some women until the third trimester when the fetus is just gaining weight"

c) Make sure the client receives nutritional counseling and reinforce the teaching Pg. 286 There are many important nursing interventions for an adolescent who is pregnant. Nutritional counseling must be emphasized as part of prenatal care for adolescent clients because adolescents already have higher nutritional demands due to their growth status. Nutrition is also a priority due to the fetus' development. Adolescents are not at increased risk for developing gestational diabetes, so the client does not need a glucose tolerance test at this time. Adolescents do need 8 to 10 hours of sleep per night, but this is not the priority education over nutrition education. Instruction on fetal development at the first visit may be overwhelming and is not the priority at this time.

21. The nurse is praising an adolescent for seeking health care as soon as the adolescent found out about being pregnant. Which nursing intervention is the priority for this client in the first trimester of pregnancy? a) Schedule the client for a screening glucose tolerance test b) Teach the client about needing 8 to 10 hours of sleep each night c) Make sure the client receives nutritional counseling and reinforce the teaching d) Instruct on fetal development throughout the pregnancy

c) Inadequate calcium for skeletal growth Pg. 292 Lactose intolerance can lead to inadequate calcium intake, which can impact fetal skeletal growth. There are many nondairy sources of protein. Iron and folate intake are not altered by lactose intolerance.

24. When caring for a client with lactose intolerance, the nurse would be aware of which potential problem during pregnancy? a) Inadequate folate for neural tube closure b) Inadequate iron for red blood cell production c) Inadequate calcium for skeletal growth d) Inadequate protein for muscle development

c) 25 to 35 lb (11 to 16 kg) Pg. A pregnant client whose weight falls into the normal BMI category (18.5 to 24.9) should aim to gain 25 to 35 lb (11 to 16 kg); pregnant clients whose weight falls in the underweight BMI category (less than 18.5) should gain 28 to 40 lb (13 to 18 kg); pregnant clients whose weight falls in the overweight BMI category (a BMI over 25 to 29.9) should gain 15 to 25 lb (7 to 11 kg); and pregnant clients whose weight falls in the obese BMI category (more than 30) should gain 11 to 20 lb (5 to 9 kg).

30. A pregnant client early in the first trimester asks the nurse how much weight to gain during the pregnancy. The nurse reviews the client's history and notes that the client's body mass index (BMI) is 23.6. Which amount will the nurse recommend? a) 11 to 20 lb (5 to 9 kg) b) 28 to 40 lb (13 to 18 kg) c) 25 to 35 lb (11 to 16 kg) d) 15 to 25 lb (7 to 11 kg)

c) Deficient fluid volume Pg. 304 The nurse should identify deficient fluid volume as a risk that needs immediate attention. The client may be at risk for hyperemesis gravidarum if she is dehydrated. Disturbed body image, deficient knowledge, or slow weight gain are not concerns that need immediate attention. The nurse attends to the client's concerns regarding disturbed body image and deficient knowledge by preparing a teaching plan with regard to exercise and hormonal changes during pregnancy. The nurse should prepare a diet plan that would help the client to receive adequate nutrition and achieve the desired weight gain.

31. A nurse assesses a primigravida client in the eighth week of gestation. The client reports nausea and vomiting in the mornings. The client tells the nurse, "I'm not able to keep liquids down and I'm eating like a bird." The client also expresses concerns about hormonal changes and how the pregnancy will affect her physical appearance. Which client problem should the nurse assess first? a) Slow weight gain b) Knowledge deficit c) Deficient fluid volume d) Disturbed body image

a) Delay eating breakfast until the nausea and vomiting has passed c) Take small amounts of liquids between meals, not with them e) Eat a saltine cracker before getting out of bed in the morning Pg. 297 Eating a saltine cracker before getting out of bed, delaying breakfast, and taking small amount of liquids between meals are all appropriate interventions to cope with morning sickness. Morning sickness is related to hormone levels. The fat, protein, or carbohydrate content of the diet is not the causative factor.

32. A client reports prolonged nausea, vomiting every morning for the past week, and no appetite. The pregnancy test comes back positive. What recommendation should the nurse give this client? Select all that apply. a) Delay eating breakfast until the nausea and vomiting has passed b) Eat a low-fat diet and eliminate all caffeine c) Take small amounts of liquids between meals, not with them d) Eat a high-protein, low-carb snack during the night e) Eat a saltine cracker before getting out of bed in the morning

a) Taking a folic acid supplement Pg. 289 All of the instructions are important when the client has the noted family history but, when having a niece with spina bifida, it is important to encourage the client to take a folic acid supplement. A minimum of 400 mcg of folic acid (vitamin B9) is recommended in pregnancy to prevent neural tube defects, including spina bifida. Some guidelines recommend beginning folic acid supplements up to 12 weeks prior to pregnancy and continuing through the first trimester. This is timely instruction at the first prenatal visit. Completing breast examinations and exercising are overall healthy choices. Blood pressure monitoring should be completed throughout pregnancy as the risk for gestational hypertension increases throughout the pregnancy.

5. The nurse is assessing a pregnant client's family history at the first prenatal visit. The client states that heart disease, diabetes and breast cancer are in the family and that a niece has spinal bifida. Which instruction is most important at this time? a) Taking a folic acid supplement b) Monitoring blood pressure during pregnancy c) Completing breast examinations monthly d) Exercising 20 to 30 minutes daily

b) Excessive vomiting Pg. 304 Excessive vomiting is a warning sign in the first trimester. Dyspnea, lower abdominal pressures, and swelling of face or extremities may occur late in pregnancy.

6. The nurse is describing pregnancy danger signs to a pregnant woman who is in her first trimester. Which danger sign might occur at this point in her pregnancy? a) Dyspnea b) Excessive vomiting c) Swelling of extremities d) Lower abdominal pressure