A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever.

What instruction should the nurse give to this client?

Remain on clear liquids until the vomiting subsides.

Take nothing by mouth until there is no more nausea.

Come to the clinic to be seen by a healthcare provider.

Make an appointment at the clinic if a fever occurs.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While remaining on clear liquids until the vomiting subsides may seem like a reasonable approach, it may not be the best course of action for a pregnant woman who has been vomiting for 24 hours. This is because prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus.

Choice B rationale

Taking nothing by mouth until there is no more nausea is not advisable in this situation. Nausea can persist even after vomiting has stopped, and it’s important for the woman to stay hydrated and nourished.

Choice C rationale

The best course of action in this situation is for the woman to come to the clinic to be seen by a healthcare provider. This is because prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus. In addition, the healthcare provider can assess the woman’s condition and provide appropriate treatment.

Choice D rationale

Making an appointment at the clinic if a fever occurs is not the best advice in this situation. While it’s important to seek medical attention if a fever develops, the woman should not wait for this to happen before seeking help. Prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus, and should be addressed promptly.

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Correct Answer is B

Explanation

Choice A rationale

While nausea and vomiting can occur in the postpartum period, they are not the highest priority for a client with a history of rheumatic fever and heart damage. These symptoms are usually self-limiting and can be managed with antiemetics.

Choice B rationale

Fluid volume excess is the highest priority for a client with a history of rheumatic fever and heart damage. Rheumatic heart disease can result in impaired heart function, making it difficult for the heart to handle increased fluid volumes that occur during pregnancy and the postpartum period. This can lead to heart failure.

Choice C rationale

While sleep deprivation can occur in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. Adequate rest is important for recovery, but it does not directly address the client’s risk of heart failure.

Choice D rationale

While infection is a concern in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. While infection can exacerbate heart failure, the immediate concern is managing the client’s fluid volume to prevent heart failure.

A. Conduct a gestational age assessment. B. Weigh and measure the newborn. C. Evaluate the neonatal reflexes’ reactivity. D. Perform a drug screen for cocaine.

Correct Answer is D

Explanation

Choice A rationale

While conducting a gestational age assessment is important, it is not the priority in this situation.

Choice B rationale

Weighing and measuring the newborn are routine procedures, but they are not the priority when the newborn is showing signs of distress.

Choice C rationale

Evaluating the neonatal reflexes’ reactivity is an important part of the newborn assessment, but it is not the priority in this situation.

Choice D rationale

Performing a drug screen for cocaine is the priority in this situation. The symptoms described - shakiness, a fast heart rate, and high blood pressure - can be signs of neonatal abstinence syndrome, which can occur if the mother used certain drugs, such as cocaine, during pregnancy.

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A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever.What instruction should the nurse give to this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever.

What instruction should the nurse give to this client?