A nurse is caring for a 20-year-old female client in an antepartum unit. The client is a primigravida at 11 weeks of gestation and reports increased nausea and vomiting within the past week, with decreased appetite. The client denies abdominal or epigastric pain but notes weight loss of 2.8 kg (6.2 lb) over the past two weeks.
Complete the diagram by dragging from the choices below to specify:
- The condition the client is most likely experiencing.
- Two actions the nurse should take to address the condition.
- Two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale for correct condition: Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy, leading to dehydration, weight loss, and electrolyte imbalance. The client's significant weight loss of 2.8 kg (6.2 lb) in two weeks, increased nausea and vomiting, and decreased appetite are classic symptoms. The elevated BUN level suggests dehydration, which aligns with hyperemesis gravidarum. The absence of abdominal pain and the presence of facial pallor further support this condition.
Rationale for actions:
- Initiate IV fluid therapy to rehydrate the client and correct electrolyte imbalances caused by excessive vomiting.
- Administer ondansetron IV to control nausea and vomiting, improving the client's ability to tolerate oral intake.
Rationale for parameters:
- Weight should be monitored to assess the effectiveness of interventions and ensure the client is regaining or maintaining a healthy weight.
- Urine output indicates hydration status and kidney function, helping to evaluate the adequacy of fluid replacement.
Rationale for incorrect conditions:
- Cholecystitis: The client denies abdominal or epigastric pain, which is a key symptom of cholecystitis.
- Gestational diabetes mellitus: There is no mention of elevated blood glucose levels or other diabetic symptoms.
- Preeclampsia: The client's blood pressure is within normal range, and there are no signs of hypertension or proteinuria.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months is incorrect. This schedule delays the immune response and leaves the infant unprotected during the critical early period when the risk of transmission is highest.
Choice B rationale
Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth is the correct approach. This combination provides immediate passive immunity through the immune globulin and active immunity through the vaccine, significantly reducing the risk of hepatitis B transmission from mother to child.
Choice C rationale
Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen is incorrect. Monthly administration alone is insufficient without the initial dose of immune globulin, especially since the infant may remain at risk until the negative test result.
Choice D rationale
Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days is incorrect. The delay in the first vaccine dose reduces its efficacy, and the immune globulin schedule does not align with established guidelines for preventing hepatitis B transmission.
Correct Answer is B
Explanation
Choice A rationale
Maintaining a folic acid intake of 4 mcg per day is not sufficient. The recommended dose for pregnant women is 400-800 mcg to help prevent neural tube defects, but it is not specifically related to reducing the risk of preterm labor.
Choice B rationale
Increasing fluid intake to 8-10 (8 oz) glasses per day is recommended as it helps to maintain hydration, which is crucial in preventing preterm labor. Dehydration can cause uterine contractions, which can lead to preterm labor.
Choice C rationale
Consuming the recommended daily allowance of vitamin C (85 mg) is important for immune function and overall health but does not directly affect the risk of preterm labor.
Choice D rationale
Increasing caloric intake by 500 calories per day is typically recommended for breastfeeding mothers, not for preventing preterm labor during pregnancy. Proper nutrition is important, but overconsumption can lead to excessive weight gain.
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