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
Each feeding should last between 20 and 30 minutes to ensure the baby gets enough nutrition and to facilitate bonding time.
Choice B rationale
Prepared formula should be used within 24 hours if stored in the refrigerator, not 5 days, to prevent bacterial growth and ensure the baby's safety.
Choice C rationale
Formula left at room temperature should not be refrigerated for reuse; it can develop bacteria that may harm the baby.
Choice D rationale
It is recommended to burp the baby multiple times during feeding to release swallowed air and prevent discomfort or spitting up.
Correct Answer is B
Explanation
Choice A rationale
Chemotherapy is not a standard treatment for a molar pregnancy unless malignancy is suspected or confirmed. It is usually monitored with regular HCG levels and follow-up.
Choice B rationale
Attending a support group is crucial for emotional support and ensuring that the client has access to resources and information about recovery and future pregnancy planning.
Choice C rationale
Home palliative services are not typically required after a molar pregnancy unless there are specific complications that necessitate such care. The focus is generally on monitoring HCG levels and follow-up.
Choice D rationale
An amniocentesis is not needed after a molar pregnancy. Follow-up includes HCG level monitoring to ensure all molar tissue is gone and to watch for malignancy, not amniocentesis.
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