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?

The correct answer is choice d. Administering broad-spectrum antibiotics.

Choice A rationale:

Cleansing the site with povidone-iodine is not recommended because it can be irritating and potentially harmful to the exposed neural tissue.

Choice B rationale:

Monitoring the rectal temperature every 4 hours is not appropriate as it can increase the risk of infection and trauma to the site. Axillary temperature monitoring is preferred.

Choice C rationale:

Preparing for surgical closure after 72 hours is incorrect. Surgical closure is typically performed within the first 24 to 48 hours to prevent infection and further damage to the neural tissue.

Choice D rationale:

Administering broad-spectrum antibiotics is crucial to prevent infection, especially since the cerebrospinal fluid is leaking, which increases the risk of meningitis and other infections.

The correct answer is choiceb. Do you notice increased cramping with breastfeeding?

Choice A rationale:Swelling in the feet is not directly related to the need for PRN pain medication following a cesarean birth. Swelling can be a common postpartum symptom due to fluid retention and changes in blood chemistry, but it does not specifically indicate pain that requires medication.

Choice B rationale:Increased cramping with breastfeeding is a common occurrence due to the release of oxytocin, which causes uterine contractions. This can be quite painful and may necessitate PRN pain medication to manage the discomfort.

Choice C rationale:Leakage from the incision could indicate a complication such as infection or wound dehiscence. While this is a serious concern that requires medical attention, it is not directly related to the typical pain management needs following a cesarean birth.

Choice D rationale:The ability to pass gas is an important indicator of the return of bowel function after surgery, but it is not directly related to the need for PRN pain medication. It is more relevant to assessing gastrointestinal recovery rather than pain levels.