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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While measuring vital signs is important, it is not the most appropriate action based on the given symptoms.
Choice B rationale
Obtaining human chorionic gonadotropin levels is the most appropriate action. The symptoms described by the client could indicate a possible miscarriage or ectopic pregnancy, and hCG levels can help confirm this.
Choice C rationale
Collecting a urine sample for urinalysis is not the most appropriate action based on the given symptoms.
Choice D rationale
Recommending bed rest is not the most appropriate action based on the given symptoms.
Correct Answer is B
Explanation
Choice A rationale
Administering oxygen via facemask is a common intervention for variable decelerations, but it is not the first action that should be taken.
Choice B rationale
Changing the client’s position is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.
Choice C rationale
Turning off the oxytocin infusion is another intervention for variable decelerations, but it is not the first action that should be taken.
Choice D rationale
Assessing cervical dilation is not the first action that should be taken in response to variable decelerations.
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