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 C

Explanation

Choice A rationale
A protective environment is not typically required for clients with MRSA141516. This type of precaution is usually used for clients who are severely immunocompromised and need to be protected from any potential sources of infection.
Choice B rationale
Droplet precautions are not typically used for clients with MRSA141516. These precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis.
Choice C rationale
Contact precautions are recommended for clients with MRSA141516. This involves using personal protective equipment and limiting patient movement outside of the room.
Choice D rationale
Airborne precautions are not typically used for clients with MRSA141516. These precautions are used for diseases that are spread through tiny airborne droplets, such as tuberculosis or chickenpox.

A. Score of 9 on postpartum day 2. B. Score of 11 on postpartum day 30. C. Discharge teaching completed. D. Will follow-up with provider in 4 weeks.

Correct Answer is B

Explanation

Choice A rationale
A score of 9 on the Edinburgh Postnatal Depression Screen (EPDS) on postpartum day 2 is below the clinical cutoff score of 10, which is used to distinguish health controls versus possible depression. Therefore, this score would not indicate a high risk of developing a depressive disorder.
Choice B rationale
A score of 11 on the EPDS on postpartum day 30 is above the clinical cutoff score of 1034. This score indicates a high risk of developing a depressive disorder. Therefore, further assessment and possible intervention would be necessary.
Choice C rationale
While discharge teaching is an important aspect of postpartum care, it does not provide information about the client’s risk of developing postpartum depression. Therefore, this choice does not answer the question.
Choice D rationale
A follow-up appointment with a provider in 4 weeks is a standard part of postpartum care, but it does not provide information about the client’s risk of developing postpartum depression.
Therefore, this choice does not answer the question.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus (MRSA). Which type of isolation precautions should the nurse initiate?

Correct Answer is C

Explanation

A nurse is assessing a postpartum client during a follow-up visit. What was the client’s score on the Edinburgh Postnatal Depression Screen?

Correct Answer is B

Explanation

A nurse is caring for a client who is in the second stage of labor and is experiencing shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

“A nurse is caring for a patient who is at 36 weeks of gestation and has a confirmed intrauterine fetal demise. Which of the following treatment options should the nurse anticipate the provider to discuss with the patient?”

A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?

A nurse is planning care for a client who is 1 hour postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?

A nurse is reviewing the prescriptions for a pregnant client who is taking digoxin. Which action should the nurse take to best evaluate the client’s medication adherence?

A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which statement by a parent indicates an understanding of the teaching?

A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?

A nurse is providing care to a client who is receiving an epidural block with an opioid analgesic. Which of the following findings should the nurse monitor as a potential adverse effect of the medication?