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 C
Explanation
Choice A rationale
A rubella titer of 1: indicates the presence of antibodies against the rubella virus, but this does not confirm the absence of a current infection. The titer represents past exposure or vaccination rather than an active infection.
Choice B rationale
A rubella titer of 1: suggests immunity to the rubella virus, making vaccination unnecessary at this time. Vaccination is typically recommended for those without immunity to prevent future infection.
Choice C rationale
A titer of 1: indicates the presence of antibodies sufficient to confer immunity to the rubella virus. This level is generally considered protective, implying the client has either had the infection before or has been vaccinated.
Choice D rationale
A mild rubella infection would not typically be determined solely by the titer level. Clinical symptoms and further diagnostic tests are required to diagnose an active rubella infection accurately.
Correct Answer is A
Explanation
Choice A rationale
At 9 weeks gestation, the primary purpose of an ultrasound is to confirm the presence of a fetal heartbeat, which indicates a viable pregnancy.
Choice B rationale
Chromosomal defects are typically assessed using different tests, such as chorionic villus sampling or amniocentesis, rather than an ultrasound at this early stage.
Choice C rationale
Fetal lung maturity cannot be assessed at 9 weeks gestation because the lungs are not yet developed. This assessment is usually done later in pregnancy if preterm delivery is anticipated.
Choice D rationale
The position of the fetus in utero is not a concern at this early stage of pregnancy. Fetal positioning becomes relevant later in pregnancy, closer to delivery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
