A client at 10 weeks gestation presents to the clinic reporting persistent nausea and vomiting. She states she is unable to keep food down and has lost 6 pounds in the last 2 weeks. Her urine appears dark, and she feels dizzy when standing. What is the nurse's priority concern?
Iron deficiency
Hyperemesis gravidarum
Gastroenteritis
Normal morning sickness
The Correct Answer is B
Hyperemesis gravidarum is a severe complication characterized by intractable vomiting leading to fluid-electrolyte imbalance, ketonuria, and weight loss exceeding 5% of pre-pregnancy mass. The pathophysiology involves high serum hCG levels and potential hyperthyroidism. Patients exhibit signs of intravascular dehydration and metabolic alkalosis.
A. Iron deficiency: While anemia is common in pregnancy, it typically presents with fatigue and pallor rather than acute, persistent emesis and significant weight loss. Iron supplements can actually exacerbate gastric irritation and nausea. It is not the primary cause of the severe hemodynamic instability described here.
B. Hyperemesis gravidarum: The combination of 6-pound weight loss, persistent inability to retain nutrients, and orthostatic dizziness indicates a pathological state beyond normal morning sickness. This condition requires aggressive intravenous rehydration and electrolyte replacement. Dark urine and dizziness are clinical hallmarks of severe volume depletion.
C. Gastroenteritis: An acute infection of the digestive tract usually presents with diarrhea, fever, and abdominal cramping alongside vomiting. While it causes temporary dehydration, the 10-week gestational timing and lack of lower gastrointestinal symptoms point toward a pregnancy-induced etiology. It is typically a self-limiting viral or bacterial event.
D. Normal morning sickness: Physiological nausea of pregnancy usually peaks in the morning and does not result in significant weight loss or clinical dehydration. Clients can typically maintain some oral intake and do not experience dizziness upon standing. It lacks the severe metabolic consequences seen in hyperemesis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Contraception and infection prophylaxis aim to interrupt the transmission of pathogenic microorganisms and the fertilization of the ovum. While barrier methods reduce risk, they carry failure rates due to mechanical rupture or improper use. Absolute prevention requires the total avoidance of mucosal contact and gamete exchange.
A. Abstinence: Total avoidance of sexual activity is the only 100% effective method to prevent both conception and the transmission of sexually transmitted infections. It eliminates exposure to infectious secretions and the possibility of sperm-egg interaction. This is the only definitive answer for absolute prevention.
B. Birth control patch: The transdermal patch releases synthetic hormones to inhibit ovulation but provides zero protection against viral or bacterial infections. It relies on systemic absorption through the skin to prevent pregnancy only. It is ineffective for preventing the spread of STIs like HIV or syphilis.
C. Birth control pills: Oral contraceptives regulate the endocrine system to prevent the release of an egg but do not create a physical barrier against pathogens. They offer high efficacy for pregnancy prevention when taken consistently. They do not mitigate the risk of acquiring or transmitting infections.
D. IUD: Intrauterine devices are highly effective long-acting reversible contraceptives that prevent implantation or fertilization within the uterus. They do not protect the vaginal or cervical mucosa from pathogenic exposure during intercourse. Their utility is strictly limited to preventing gestation, not disease transmission.
Correct Answer is B
Explanation
Fetal engagement occurs when the biparietal diameter of the fetal head passes through the pelvic inlet into the true pelvis. This is clinically identified when the presenting part reaches the level of the maternal ischial spines, designated as 0 station. It signifies that the fetal head is no longer ballotable.
A. Birth is complete: Delivery of the neonate is only finalized when the entire body has exited the vaginal canal, followed by the third stage of labor. A 0 station indicates the fetus is only at the mid-pelvic level. Significant expulsive effort and descent are still required for birth.
B. Engagement: Reaching 0 station confirms that the widest part of the head has successfully entered the pelvic cavity. In nulliparous clients, this often occurs before the onset of labor, while in multiparous clients, it may happen during the active phase. It is a key pelvic landmark.
C. Placenta delivery: The third stage of labor involves the detachment and expulsion of the placenta after the fetus is born. This occurs well after the fetus has passed the 0 station and the vaginal introitus. It is unrelated to the mechanical station of the fetal head.
D. Full dilation: Dilation refers to the opening of the cervix to 10 centimeters and is an assessment of the birth canal rather than fetal position. While engagement often coincides with progress in labor, a client can be at 0 station without being fully dilated. They are independent clinical measurements.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.