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A nurse is caring for the client at the next prenatal visit.

Exhibits

After reviewing the assessment findings, which of the following complications is the client at an Increased risk for developing?

Select the 3 complications the client is at an increased risk for developing.

Thromboembolism

Electrolyte imbalance

Fetal growth restriction

Polyhydramnios

Gestational diabetes mellitus

Spontaneous abortion

Answer and Explanation

Correct Answer : B,C,F

A. Thromboembolism:

Thromboembolism refers to the formation of blood clots (thrombi) that break loose and travel through the bloodstream, potentially causing blockages in blood vessels (embolism). While thromboembolism is a risk in pregnancy, especially in individuals with risk factors such as obesity or a history of thromboembolic events, there are no specific indications in the scenario provided that suggest an increased risk of thromboembolism for this client.

B. Electrolyte imbalance:

The client's persistent nausea, vomiting, and ketonuria indicate significant dehydration and electrolyte imbalances. Dehydration can lead to imbalances in electrolytes such as potassium, sodium, and chloride, which are essential for proper bodily function. Laboratory findings of low potassium (hypokalemia) and elevated blood urea nitrogen (BUN) support the presence of electrolyte imbalances. These imbalances can have serious consequences for both the client and the fetus, including cardiac arrhythmias, muscle weakness, and metabolic disturbances.

C. Fetal growth restriction:

Hyperemesis gravidarum, characterized by severe nausea and vomiting leading to dehydration and weight loss, is associated with an increased risk of fetal growth restriction. Inadequate maternal nutrition and dehydration can compromise fetal growth and development, potentially leading to a smaller-than-expected size for gestational age. The client's weight loss and ketonuria further support the possibility of fetal growth restriction due to insufficient nutrient intake and placental perfusion.

D. Polyhydramnios:

Polyhydramnios refers to an excess of amniotic fluid surrounding the fetus in the uterus. While hyperemesis gravidarum and dehydration can lead to maternal complications, such as electrolyte imbalances and fetal growth restriction, they are not typically associated with an increased risk of polyhydramnios. Polyhydramnios is more commonly linked to fetal anomalies, maternal diabetes, or fetal conditions that affect swallowing or fluid regulation, none of which are evident in the provided scenario.

E. Gestational diabetes mellitus:

Gestational diabetes mellitus (GDM) is a condition characterized by high blood sugar levels during pregnancy. While GDM can lead to various complications for both the mother and the fetus, including macrosomia (large birth weight), birth injuries, and neonatal hypoglycemia, there are no indications in the scenario provided that suggest an increased risk of GDM for this client.

F. Spontaneous abortion:

Hyperemesis gravidarum, with severe nausea, vomiting, and weight loss, is associated with an increased risk of spontaneous abortion or miscarriage. Dehydration, electrolyte imbalances, and maternal malnutrition can compromise maternal and fetal well-being, potentially leading to pregnancy loss. Therefore, the client is at an increased risk of spontaneous abortion due to the severity of her symptoms and the impact on her overall health and pregnancy.

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Correct Answer is D

Explanation

Explanation:

A. Airborne precautions:

Airborne precautions are used for pathogens that are transmitted through the air over long distances. This includes pathogens such as Mycobacterium tuberculosis (TB) or varicella-zoster virus (chickenpox). However, Clostridium difficile (C. difficile) infection is not transmitted through the airborne route. Therefore, airborne precautions are not appropriate for managing C. difficile infection.

B. Droplet precautions:

Droplet precautions are used for pathogens that are transmitted through respiratory droplets, typically over short distances (usually within about 3 feet). This includes pathogens such as influenza virus or Bordetella pertussis (whooping cough). However, C. difficile infection is primarily transmitted through the fecal-oral route and contact with contaminated surfaces or objects, rather than through respiratory droplets. Therefore, droplet precautions are not appropriate for managing C. difficile infection.

C. Protective environment:

Protective environment, also known as reverse isolation, is used to protect immunocompromised clients from pathogens in the environment. This includes clients who have undergone bone marrow transplantation or chemotherapy. However, protective environment precautions are not appropriate for managing C. difficile infection. C. difficile infection control measures primarily focus on preventing the spread of the infection to others, rather than protecting the client from external pathogens.

D. Contact precautions:

Contact precautions are used for pathogens that are transmitted through direct or indirect contact with the client or their environment. This includes pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) or C. difficile. C. difficile infection is primarily transmitted through contact with contaminated surfaces or objects. Therefore, contact precautions, which involve measures to prevent the transmission of infectious agents via contact, including wearing gloves and a gown, performing hand hygiene, and ensuring environmental cleaning and disinfection, are appropriate for managing C. difficile infection.

A. Turn the newborn every 4 hr. B. Close the newborn's eyes before applying eyepatches. C. Provide the newborn with 15 mL glucose water after each feeding. D. Apply hydrating lotion to the newborn's skin prior to treatment.

Correct Answer is B

Explanation

A. Turn the newborn every 4 hr:

Turning the newborn every 4 hours is a routine nursing intervention to prevent pressure ulcers in infants. However, it is not specifically related to phototherapy treatment. Turning the newborn should be done as per routine care, but it is not a direct action related to phototherapy.

B. Close the newborn's eyes before applying eyepatches:

It is important to protect the newborn's eyes from the bright light used in phototherapy. Therefore, closing the newborn's eyes before applying eyepatches or covering them with eye protection is necessary during phototherapy to prevent eye damage.

C. Provide the newborn with 15 mL glucose water after each feeding:

Providing glucose water after each feeding is not a standard practice for newborns undergoing phototherapy. Instead, the primary focus during phototherapy is on feeding the baby adequately to promote hydration and excretion of bilirubin through stool and urine. Glucose water is not routinely recommended unless specifically ordered by the healthcare provider for a medical indication.

D. Apply hydrating lotion to the newborn's skin prior to treatment:

Hydrating lotion should not be applied to the newborn's skin prior to phototherapy. Lotions, oils, or creams can interfere with the effectiveness of phototherapy by creating a barrier that blocks the light from reaching the baby's skin. Therefore, it is essential to keep the baby's skin clean and free from lotions or ointments during phototherapy.

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A nurse is caring for the client at the next prenatal visit. Exhibits After reviewing the assessment findings, which of the following complications is the client at an Increased risk for developing? Select the 3 complications the client is at an increased risk for developing.

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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A nurse is caring for the client at the next prenatal visit.

Exhibits

After reviewing the assessment findings, which of the following complications is the client at an Increased risk for developing?

Select the 3 complications the client is at an increased risk for developing.