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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
(A) Lie in a left side lying position for 30 min after meals:
While lying on the left side can sometimes help alleviate heartburn, it's generally recommended to elevate the head and upper body during sleep, especially if heartburn worsens at night. Lying down immediately after meals can actually exacerbate heartburn symptoms.
(B) Drink a cup of black coffee before breakfast:
Drinking black coffee can exacerbate heartburn symptoms due to its acidic nature and caffeine content. It is not recommended for individuals experiencing frequent heartburn, especially during pregnancy.
(C) Take sips of milk between meals:
Taking sips of milk between meals can help neutralize stomach acid and provide temporary relief from heartburn symptoms. However, it's essential to avoid drinking large quantities of milk at once, as this can lead to increased stomach acid production.
(D) Eat three large meals per day:
Eating large meals can increase pressure on the stomach and exacerbate heartburn symptoms. Instead of consuming three large meals, it's better to eat smaller, more frequent meals throughout the day to help prevent heartburn.
Correct Answer is D
Explanation
(A) Diuresis:
Diuresis, or increased urine production, is not a typical adverse effect of nalbuphine hydrochloride. Opioids generally do not affect urine output in the same way as diuretic medications.
(B) Fever:
Fever is not a common adverse effect of nalbuphine hydrochloride. If a client develops a fever during labor, it could indicate other underlying causes such as infection or inflammation, but it is not directly related to the administration of this medication.
(C) Diarrhea:
Diarrhea is not a typical adverse effect of nalbuphine hydrochloride. Opioid medications are more commonly associated with constipation due to their effects on gastrointestinal motility and function.
(D) Sedation:
Nalbuphine hydrochloride is an opioid analgesic used for pain relief during labor. Sedation is a common adverse effect of opioid medications, including nalbuphine. Opioids can depress the central nervous system, leading to drowsiness, sedation, and decreased level of consciousness. It's essential for the nurse to monitor the client closely for signs of sedation, especially during labor, to ensure the safety of both the mother and the baby.
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