A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the following findings should the nurse anticipate?

Increased fundal height

Poor skin turgor

Decreased pulse rate

Proteinuria

Answer and Explanation

The Correct Answer is B

(A) Increased fundal height:
Hyperemesis gravidarum, severe nausea, and vomiting during pregnancy, typically does not cause an increased fundal height. Fundal height may be normal or even decreased due to dehydration and weight loss.

(B) Poor skin turgor:
Poor skin turgor is a common finding in clients with hyperemesis gravidarum due to dehydration. Excessive vomiting leads to fluid loss and dehydration, resulting in poor skin elasticity and turgor.

(C) Decreased pulse rate:
Hyperemesis gravidarum usually results in dehydration and hypovolemia, which can lead to an increased heart rate rather than a decreased pulse rate. The body compensates for decreased fluid volume by increasing the heart rate to maintain adequate circulation.

(D) Proteinuria:
Proteinuria, the presence of abnormal amounts of protein in the urine, is not typically associated with hyperemesis gravidarum. Proteinuria can be a sign of kidney dysfunction or other medical conditions but is not directly related to severe nausea and vomiting during pregnancy.

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Correct Answer is B

Explanation

(A) Tell the client to apply hydrocortisone ointment to the affected area of the breast:
Hydrocortisone ointment is not appropriate for treating mastitis, which is an infection of the breast tissue. The primary treatments for mastitis include antibiotics, pain management, and supportive measures like warm compresses to relieve discomfort and promote milk flow.

(B) Suggest the client apply warm compresses to the affected breast:
Applying warm compresses to the affected breast can help relieve pain and promote milk flow, which can aid in resolving the infection. Warmth can help reduce inflammation and make breastfeeding or pumping less painful.

(C) Recommend the client avoid wearing a nursing bra until symptoms resolve:
Avoiding a nursing bra is not necessary. In fact, wearing a well-fitting and supportive nursing bra can help manage discomfort and support the breasts. It is important that the bra is not too tight to avoid further compression and blockage of milk ducts.

(D) Encourage the client to limit oral fluid intake to decrease milk production:
Limiting fluid intake is not recommended. Adequate hydration is important for overall health and maintaining milk supply. Reducing fluid intake does not effectively manage mastitis and can lead to dehydration.

A. Supine B. Prone C. Left lateral D. Right lateral

Correct Answer is A

Explanation

(a) Supine
Placing the newborn in the supine position (on their back) for sleep is recommended by pediatric guidelines to reduce the risk of sudden infant death syndrome (SIDS) and other sleep-related causes of infant death. The supine position allows for optimal airway patency and decreases the risk of suffocation. This position is safest for the newborn during sleep.

(b) Prone
Placing the newborn in the prone position (on their stomach) for sleep is not recommended due to an increased risk of SIDS. The prone position can obstruct the infant's airway and increase the risk of suffocation or overheating, leading to adverse outcomes.

(c) Left lateral
While placing the newborn on the left side may be recommended for certain medical procedures or interventions, such as feeding to reduce reflux, it is not recommended for sleep positioning. Placing the newborn in the left lateral position during sleep does not provide the same benefits for airway patency and SIDS risk reduction as the supine position.

(d) Right lateral
Similar to the left lateral position, placing the newborn on the right-side during sleep does not offer the same protective benefits as the supine position. It does not reduce the risk of SIDS and may pose similar risks as the prone position, such as airway obstruction.

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A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the following findings should the nurse anticipate?

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