A nurse in the emergency department is caring for a 19-year-old female client who is at 18 weeks of gestation. The client presents with reports of nausea and vomiting for the past several weeks, which has worsened in severity. The client states that she has been unable to retain even clear fluids for the past 48 hours. The client reports no pain but has a history of migraines and asthma.
Exhibits

Answer and Explanation

The Correct Answer is []

•   Hyperemesis gravidarum: The client’s symptoms such as severe nausea and vomiting, inability to retain clear fluids, and positive ketones in urinalysis suggest that she is most likely experiencing hyperemesis gravidarum, a pregnancy complication characterized by severe nausea, vomiting, weight loss, and electrolyte disturbance.
•   Actions to take: The nurse should administer the prescribed antiemetic medication to help control the client’s nausea and vomiting. The nurse should also provide IV fluid replacement to correct the client’s dehydration and electrolyte imbalance.
•   Parameters to monitor: The nurse should monitor the client’s urine output to assess her hydration status. The nurse should also monitor the client’s electrolyte levels, as electrolyte imbalances can occur with severe vomiting and dehydration. If the client’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.

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Correct Answer is B

Explanation

Choice A rationale
Transient occipital cyanosis is not a clinical finding that should be reported to the provider. It is a normal finding in newborns due to immature circulation and should resolve on its own.
Choice B rationale
Single palmar creases, also known as simian lines, can be a sign of certain genetic conditions, such as Down syndrome. Therefore, this finding should be reported to the provider.
Choice C rationale
Subconjunctival hemorrhage, or a red spot in the white of the eye, is a common and harmless condition in newborns. It does not require treatment and will disappear as the blood is absorbed.
Choice D rationale

Dystocia, or difficult labor, is not a clinical finding in a newborn. It refers to a situation during childbirth where there is slow or difficult labor or delivery.

A. Absent Moro reflex B. Weak cry C. Poor feeding D. Respiratory rate of 30/min

Correct Answer is B

Explanation

Choice A rationale
An absent Moro reflex is not typically associated with neonatal abstinence syndrome (NAS), a condition that can occur in newborns exposed to opioids in utero.
Choice B rationale
A weak cry is a common symptom of NAS. Newborns with this syndrome often have high- pitched or weak cries.
Choice C rationale
Poor feeding is a symptom of NAS, but it is not the most specific symptom in this context.
Choice D rationale
A respiratory rate of 30/min is within the normal range for a newborn and is not indicative of NAS5.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a full-term newborn upon admission to the nursery. What clinical findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is assessing a newborn of a client who reported methadone use during pregnancy. What manifestations should the nurse expect the newborn to exhibit?

Correct Answer is B

Explanation

A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. What clinical findings should the nurse expect?

A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which food selection has the highest fiber content per cup?

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?

A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates understanding of the teaching?