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A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum.

Exhibits


The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?

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 condition.

A.

Urinary output 40 ml/hr

B.

3+ ketones

C.

Heart rate 100/min

D.

WBC count 10000/mm3

E.

Urine specific gravity 1050

F.

Urine pH 5

Answer and Explanation

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

For the findings 24 hours later, the nurse should interpret them as follows:

 Urinary output: 40 ml/hr

Interpretation: Sign of potential worsening condition

Explanation: A urinary output of 40 ml/hr is concerning and indicates potential dehydration. It is a sign of potential worsening of the client's condition, as it suggests inadequate fluid intake or ongoing fluid losses.

3+ ketones

Interpretation: Sign of potential worsening condition

Explanation: The presence of 3+ ketones in the urine suggests ongoing ketosis, which can occur in hyperemesis gravidarum due to starvation and the breakdown of fats for energy. It is a sign of potential worsening of the client's nutritional status.

Heart rate: 100/min

Interpretation: Sign of potential improvement

Explanation: A heart rate of 100/min is within the normal range. It can be interpreted as a sign of potential improvement, indicating that the client's cardiovascular system is maintaining an appropriate heart rate.

WBC count: 10,000/mm3

Interpretation: Unrelated to diagnosis

Explanation: The WBC count within the normal range (10,000/mm3) is unrelated to the diagnosis of hyperemesis gravidarum. It does not provide specific information about the client's condition in this context.

Urine specific gravity: 1.050

Interpretation: Sign of potential worsening condition

Explanation: A urine specific gravity of 1.050 is elevated and indicates concentrated urine. This finding is a sign of potential worsening of the client's dehydration status.

Urine pH: 5

Interpretation: Unrelated to diagnosis

Explanation: The urine pH of 5 is within the normal range and is unrelated to the diagnosis of hyperemesis gravidarum. It does not provide specific information about the client's condition in this context.


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Related Questions

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

Explanation

a. Muscle tone: flaccid Interpretation: This finding suggests a lack of muscle tone, which could be concerning. It may indicate a neurological issue or possible birth trauma. Interpretation: Indication that the client's condition is worsening. b. Respiration effort: good cry Interpretation: A good cry indicates that the newborn is able to breathe properly and is responsive. Interpretation: Indication that the client's condition is improving. c. Reflex irritability: cry Interpretation: The newborn's ability to cry in response to stimuli is a positive sign of reflex irritability and neurological function. Interpretation: Indication that the client's condition is improving. d. Color consistent with genetic background Interpretation: This suggests that the newborn's skin color is within the range typical for their genetic background. Interpretation: Unrelated to the diagnosis. e. Heart rate 140/min Interpretation: A heart rate of 140 beats per minute is within the normal range for a newborn. Interpretation: Unrelated to the diagnosis. f. Axillary temperature 36.3°C (97.4°F) Interpretation: A temperature of 36.3°C (97.4°F) is within the normal range for a newborn. Interpretation: Unrelated to the diagnosis.

Correct Answer is B

Explanation

A. Postpartum hemorrhage: Effacement and dilation relate to the progress of labor, not postpartum hemorrhage. Postpartum hemorrhage is excessive bleeding that occurs after childbirth, typically within 24 hours, and can have various causes unrelated to cervical dilation.

B. Incompetent cervix: Incompetent cervix, also known as cervical insufficiency, refers to the premature and painless dilation of the cervix during the second trimester of pregnancy. It is not directly related to the dilation mentioned in the scenario. However, it is possible that the client may have misunderstood the timing of contractions, and the nurse should assess for other signs of cervical insufficiency.

C. Hyperemesis gravidarum: Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, which can lead to dehydration and electrolyte imbalances. It is not directly related to cervical dilation or effacement.

D. Ectopic pregnancy: An ectopic pregnancy is a pregnancy that occurs outside the uterus, usually in the fallopian tube. Cervical dilation and effacement are not associated with ectopic pregnancies.

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