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.

Urinary output 40 ml/hr

3+ ketones

Heart rate 100/min

WBC count 10000/mm3

Urine specific gravity 1050

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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Correct Answer is B

Explanation

A. Obtain an imprint of the infant’s feet prior to taking him to the nursery: While obtaining an imprint of the infant’s feet can be a sentimental and identification measure, the immediate focus should be on checking the newborn's identification using more standard and immediate methods.

B. Check the newborn's identification using the crib card: This is the correct answer. Checking the newborn's identification against the crib card or other hospital-issued identification is a crucial step in ensuring accurate and secure identification. This should be done consistently by healthcare providers during any interactions or care procedures involving the newborn.

C. Replace the infant’s identification band after his name has been recorded: The policy should emphasize the importance of maintaining the integrity of the newborn's identification band, but it should not specifically state that it needs to be replaced after the name has been recorded.

D. Require visitors to wear an identification band: While visitor identification may be important for security reasons, the primary focus of this policy should be on the identification of the newborn. The responsibility for accurate identification lies primarily with healthcare providers.

A. Offer the newborn 30 ml (1 oz) of water between feedings. B. Allow the baby to feed at least every 3 hr C. Expect two to four wet diapers every 24 h D. Feed the newborn 5 to 10 min per breast

Correct Answer is B

No explanation

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