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 A

Explanation

Choice A rationale
Jitteriness is a common sign of hypoglycemia in newborns. Newborns whose mothers had gestational diabetes are at an increased risk of developing hypoglycemia shortly after birth. Other signs of neonatal hypoglycemia can include poor feeding, lethargy, and seizures.
Choice B rationale
Increased muscle tone is not typically associated with hypoglycemia in newborns. However, decreased muscle tone can be a sign of severe hypoglycemia.
Choice C rationale
Abdominal distention is not typically associated with hypoglycemia in newborns. However, it can be a sign of other conditions, such as gastrointestinal obstruction or sepsis.
Choice D rationale
Petechiae, or small red or purple spots on the skin caused by bleeding into the skin, are not typically associated with hypoglycemia in newborns. However, they can be a sign of other conditions, such as infection or a bleeding disorder.

A. Maintain a low stimulation environment B. Weigh the newborn daily C. Advise the parent to avoid breastfeeding D. Avoid eye contact with the newborn during feeding E. Plan to administer naloxone F. Swaddle the newborn with flexed extremities G. Perform Ballard newborn screening each shift . .

Correct Answer is ["A","B","F"]

Explanation

Choice A rationale
Maintaining a low-stimulation environment is recommended for newborns exhibiting clinical findings of NAS56. This can help to reduce symptoms such as irritability and restlessness.
Choice B rationale
Weighing the newborn daily is important in the care of a newborn with NAS56. This can help to monitor the newborn’s growth and development, and any significant changes in weight could indicate a need for further medical intervention.
Choice C rationale
Advising the parent to avoid breastfeeding is not typically recommended for mothers who used opioids prior to pregnancy and were prescribed methadone during pregnancy. In fact, breastfeeding is often encouraged for these mothers, as it can help to reduce the severity of NAS symptoms in the newborn.
Choice D rationale
Avoiding eye contact with the newborn during feeding is not typically recommended as part of the care for a newborn with NAS56. Eye contact can help to promote bonding between the parent and the newborn.
Choice E rationale
The administration of naloxone is not typically recommended for a newborn with NAS56. Naloxone is a medication used to reverse the effects of opioids, but it is not typically used in the treatment of NAS56.
Choice F rationale
Swaddling the newborn with flexed extremities can help to comfort a newborn with NAS56. This can help to reduce symptoms such as irritability and restlessness.
Choice G rationale
This option is not typically necessary for the management of neonatal abstinence syndrome (NAS). The Ballard score is used to assess gestational age and physical maturity of a newborn, but it is not a routine part of monitoring for NAS.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?

Correct Answer is A

Explanation

Correct Answer is ["A","B","F"]

Explanation

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