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.
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.
Urine pH 5.0
Urine specific gravity 1.050
3+ ketones
Urinary output 40 mL/hr
Heart rate 130/min
WBC count 10,000/mmt
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Progressive sacral discomfort during contractions is a normal part of labor and does not necessarily require reassessment.
Choice B rationale
An urge to have a bowel movement during contractions could indicate that the baby’s head is descending into the birth canal. This could signal that the labor is progressing more quickly than expected, and the nurse should reassess the client.
Choice C rationale
Intense contractions lasting 45 to 60 seconds are a normal part of active labor and do not necessarily require reassessment.
Choice D rationale
A sense of excitement and warm, flushed skin are normal emotional and physiological responses to labor and do not necessarily require reassessment.
Correct Answer is C
Explanation
Choice A rationale
While demonstrating proper bathing of the infant is an important skill for new mothers, it is not typically a primary goal during the taking-in phase. This phase is characterized by the mother’s need to review her birth experience and begin to process her new role.
Choice B rationale
Verbalizing appropriate car seat safety is important, but it is not a primary goal during the taking-in phase. This phase is more focused on the mother’s internal processing of her birth experience.
Choice C rationale
This is the correct answer. Having adequate nutritional intake is a key goal during the taking-in phase. Good nutrition is essential for healing and recovery after childbirth, as well as for breastfeeding.
Choice D rationale
Identifying necessary family roles is an important part of adjusting to parenthood, but it is not a primary goal during the taking-in phase. This phase is more about the mother’s personal adjustment and recovery.
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.