A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Report of perineal pain as 0 on a scale of 0 to 10: Perineal pain is more directly related to the effects of spinal anesthesia rather than fluid status. A decrease in perineal pain would be expected after the administration of spinal anesthesia, but it may not specifically indicate the effectiveness of the IV bolus.
B. Report of relief of pruritus: Pruritus (itching) is a common side effect of spinal anesthesia. Relief of pruritus can be expected after the administration of spinal anesthesia, but it is not a direct indicator of the effectiveness of the IV bolus.
C. Increased urinary output: Increased urinary output may indicate improved renal perfusion or fluid balance but is not a specific indicator of the effectiveness of the IV bolus in the context of spinal anesthesia for labor.
D. Blood pressure 110/70 mm Hg: This is the correct answer. Blood pressure is an important parameter to monitor, especially after administering an IV bolus of fluids. A blood pressure within the normal range (110/70 mm Hg) suggests that the bolus has been effective in addressing any hypovolemia or dehydration.
Correct Answer is C
Explanation
A. Move the client onto their hands and knees: This position is often used for the Gaskin maneuver, which involves positioning the mother on all fours to help resolve shoulder dystocia. However, the McRoberts maneuver specifically requires hyperflexing the legs toward the abdomen.
B. Press firmly on the client’s suprapubic area: This action is not part of the McRoberts maneuver. It is not the recommended technique for resolving shoulder dystocia.
C. Assist the client in pulling their knees toward their abdomen
The McRoberts maneuver involves hyperflexing the mother's legs toward her abdomen to widen the pelvic outlet. This repositions the pelvis, which can assist in dislodging the impacted shoulder of the baby during a shoulder dystocia.
D. Apply pressure to the client’s fundus: Applying pressure to the fundus can sometimes be used in other obstetric emergencies but is not part of the McRoberts maneuver for shoulder dystocia.
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