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.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Moving the client onto their hands and knees is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Choice B rationale
Applying pressure to the client’s fundus is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Choice C rationale
This is the correct answer. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen. This maneuver helps to rotate the pelvis and open the sacrum to release the baby’s shoulder.
Choice D rationale
Pressing firmly on the client’s suprapubic area is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Correct Answer is B
Explanation
Choice A rationale
The indirect Coombs test does not determine if a baby is at risk for developing hypoglycemia after birth. It is used to screen for Rh incompatibility.
Choice B rationale
The indirect Coombs test is used to detect the presence of Rh-positive antibodies in your blood. This is particularly important in pregnancy as it can indicate a risk of Rh incompatibility.
Choice C rationale
The indirect Coombs test does not determine the amount of amniotic fluid around the fetus.
Choice D rationale
The indirect Coombs test does not assess blood flow to the fetus and placenta using ultrasound.
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