A nurse is assisting with the care of a 19-year-old female client who is at 18 weeks of gestation in the emergency department.
Complete the diagram by selecting from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Based on the information provided, the client is most likely experiencing C. Hyperemesis gravidarum. This condition is characterized by severe nausea and vomiting, which can lead to dehydration and electrolyte imbalances.
Actions to Take:
- B. Inspect mucous membranes - To assess for signs of dehydration, such as dry mucous membranes.
- D. Administer antiemetic medications - To help control nausea and vomiting.
Parameters to Monitor:
- A. Electrolyte values - To monitor for any imbalances, especially given the low potassium level.
- B. Urine ketones - To check for ketonuria, which can indicate severe vomiting and dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Amniocentesis is used to detect fetal genetic abnormalities, such as Down syndrome, by analyzing the amniotic fluid for genetic markers.
Choice B rationale
An empty bladder is required for the test only in late pregnancy to prevent bladder injury; however, in early pregnancy, a full bladder may be required to better visualize the uterus and amniotic fluid.
Choice C rationale
An x-ray is not typically used during the needle placement for amniocentesis. Ultrasound is the preferred method to guide the needle to avoid harm to the fetus and mother.
Choice D rationale
The test does not determine the volume of amniotic fluid; it is used primarily for genetic analysis, assessing fetal lung maturity, and diagnosing certain fetal infections.
Correct Answer is B
Explanation
Choice A rationale
Wearing an underwire bra is not recommended for clients with inverted nipples as it can cause discomfort and restrict milk flow. Proper support without constriction is essential.
Choice B rationale
Placing breast shells in the client's bra helps to draw out inverted nipples by applying gentle pressure, making breastfeeding easier. They also protect the nipples from friction and irritation.
Choice C rationale
Providing plastic-lined breast pads may prevent leakage, but they do not address the issue of inverted nipples. Proper nipple preparation is essential for effective breastfeeding.
Choice D rationale
Applying breast cream regularly might keep the skin hydrated, but it does not help to correct the inversion of the nipples. Mechanical aids like breast shells are more effective.
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