A nurse in the emergency department is caring for a 19-year-old patient who is at 18 weeks of gestation.

The patient presents with reports of nausea and vomiting for the past several weeks, which has worsened in severity. The patient states that they have been unable to retain even clear fluids for the past 48 hours.

The patient reports no pain.

The patient reports a history of migraines and asthma.

What condition is the patient most likely experiencing? What are two actions the nurse should take to address that condition, and what are two parameters the nurse should monitor to assess the patient’s progress?

Dehydration

Hyperemesis Gravidarum

Gastroenteritis

Food Poisoning

Answer and Explanation

The Correct Answer is B

Choice A rationale
Dehydration could be a result of prolonged nausea and vomiting, but it is not the primary condition. Dehydration is a complication, not the cause of the symptoms.
Choice B rationale
The patient is most likely experiencing Hyperemesis Gravidarum, a severe form of nausea and vomiting in pregnancy. It’s more extreme than the typical morning sickness experienced during pregnancy and can lead to weight loss and dehydration. The nurse should ensure the patient stays hydrated and monitor their weight. Antiemetic medications may be prescribed to help control the vomiting.
Choice C rationale
Gastroenteritis typically involves both vomiting and diarrhea, often accompanied by abdominal pain and fever. The patient’s symptoms do not indicate gastroenteritis.
Choice D rationale
Food poisoning is usually associated with consuming contaminated food or water and often involves symptoms such as abdominal cramps and diarrhea, which the patient does not report.

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Correct Answer is B

Explanation

Choice A rationale
Limiting the length of breastfeeding to 5 minutes per breast is not typically recommended. It’s important for the baby to empty each breast completely, as the fat content of the milk increases as the breast empties.
Choice B rationale
Assessing the newborn’s latch while breastfeeding is crucial. A poor latch can cause sore nipples. The baby should take as much of the areola into their mouth as possible, with more areola showing at the top lip than the bottom.
Choice C rationale
Waiting 4 hours between daytime feedings is not typically recommended for a breastfeeding newborn. Newborns typically need to feed every 2-3 hours, or 8-12 times in 24 hours.
Choice D rationale
Offering supplemental formula between the newborn’s feedings can interfere with establishing a good milk supply and should be avoided unless medically necessary.

A. Aspirin B. Meperidine C. Fentanyl citrate D. Ibuprofen

Correct Answer is D

Explanation

Choice A rationale
Aspirin is generally not recommended for postpartum pain management due to its anticoagulant properties, which can increase the risk of bleeding. Furthermore, if the mother is breastfeeding, aspirin can pass into breast milk and potentially harm the baby.
Choice B rationale
Meperidine is a strong opioid medication that is typically reserved for severe pain. It is not usually the first choice for postpartum pain management due to its potential side effects and the risk of dependency.
Choice C rationale
Fentanyl citrate is a potent opioid that is typically used for severe pain and is often used in anesthesia. It is not usually used for routine postpartum pain management due to its potency and the risk of side effects and dependency.
Choice D rationale
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is commonly used for postpartum pain management. It is effective for relieving perineal pain and uterine cramping, and it is safe for use in breastfeeding mothers.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is one day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is postpartum following a vaginal birth. Which analgesic medication should the nurse plan to administer and document in the client’s medical record?

Correct Answer is D

Explanation

A nurse is preparing to administer metronidazole 2 g PO to a client who has trichomoniasis. Available is metronidazole 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) .

A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which action should the nurse take?

A nurse is caring for a client who is 1 hour postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?

A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.

A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client in a hands-and-knee position. Which should the nurse ask to evaluate the effectiveness of this intervention?

A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis. How should the nurse interpret the findings 24 hr later?

A nurse is teaching a client who is experiencing infertility about clomiphene citrate. Which adverse effects should the nurse include?