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A nurse is caring for a 28-year-old female client who is at 12 weeks of gestation and has been admitted to the emergency department with excessive vomiting for the past 48 hours. The client has lost 2.3 kg (5 lb) over 2 days.

Exhibits

The nurse is assessing the client 24 hours later. How should the nurse interpret the findings 24 hours later? For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening.

A.

Urine pH 5.0

B.

Urine specific gravity 1.050

C.

3+ ketones

D.

Urinary output 40 mL/hr

E.

Heart rate 130/min

F.

WBC count 10,000/mmt

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}

  • Urine pH 5.0: This is an improvement as the pH has increased from 4.4, moving closer to the normal range (4.6 to 8).
  • Urine specific gravity 1.050: This is a sign of potential worsening as the specific gravity has increased from 1.040, indicating possible dehydration.
  • 3+ ketones: This is a sign of potential worsening as the presence of ketones has increased from 2+, indicating the body is breaking down fat for energy due to insufficient glucose.
  • Urinary output 40 mL/hr: This is an improvement as the urinary output has increased from 20 mL/hr, indicating better hydration.
  • Heart rate 130/min: This is a sign of potential worsening as the heart rate has increased from 128/min, possibly due to dehydration.
  • WBC count 10,000/mmt: This is unrelated to the diagnosis as it’s within the normal range (5,000 to 10,000/mm³) and doesn’t directly relate to the client’s symptoms of vomiting and dehydration.


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Related Questions

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"}}

Explanation

• Regurgitation: This could be a sign of potential worsening condition as it might indicate gastrointestinal issues, which can be a symptom of Neonatal Abstinence Syndrome (NAS).
• Transient strabismus: This is unrelated to the diagnosis. Strabismus is common in newborns and usually resolves on its own within the first few months of life.
• Mottling: This could be a sign of potential worsening condition. Mottling (a lacy pattern of dilated blood vessels under the skin) can be a sign of distress in a newborn.
• Respiratory rate 70/min: This could be a sign of potential worsening condition. A respiratory rate of 70/min is higher than the normal range (30-60 breaths per minute) for a newborn, indicating possible respiratory distress.
• Continuous high-pitched cry: This could be a sign of potential worsening condition. A high-pitched cry is a common symptom of NAS.
• Loose stools: This could be a sign of potential worsening condition. Loose stools can be a symptom of NAS.

Correct Answer is D

Explanation

Choice A rationale
An incompetent cervix is a condition that occurs when weak cervical tissue causes or contributes to premature birth or the loss of an otherwise healthy pregnancy. This is not typically associated with rapid labor progression.
Choice B rationale
Hyperemesis gravidarum is a condition characterized by severe nausea, vomiting, weight loss, and electrolyte disturbance. Mild cases are treated with dietary changes, rest, and antacids. It’s not related to the speed of labor progression.
Choice C rationale

An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus. It’s not related to the speed of labor progression.
Choice D rationale
Postpartum hemorrhage is the correct answer. Rapid labor progression can lead to a higher risk of postpartum hemorrhage due to uterine atony, where the uterus fails to contract after the delivery.

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