The nurse has reviewed the Vital Signs, Nurses' Notes, and Provider Notes from 1 week ago.
Select words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Rationale for correct choices
• Intrauterine growth restriction: The client has experienced persistent nausea and vomiting, reduced oral intake, and a 1.8 kg (4 lb) weight loss over 5 weeks. These factors contribute to maternal malnutrition, which can limit fetal growth and development. Early identification of inadequate maternal nutrition is critical to prevent complications such as low birth weight, preterm birth, and impaired fetal organ development.
• Thiamine deficiency: Prolonged vomiting and poor nutritional intake increase the risk of vitamin deficiencies, particularly thiamine (vitamin B1). Thiamine deficiency in pregnancy can lead to Wernicke’s encephalopathy, neurological complications, and exacerbate maternal fatigue. Prompt recognition and supplementation are essential for both maternal and fetal health.
Rationale for incorrect choices
• Hypernatremia: While dehydration may accompany vomiting, severe vomiting usually leads to hyponatremia and hypokalemia (electrolyte loss) along with metabolic alkalosis. Hypernatremia is less likely than other complications in this scenario, as the client’s main concern is inadequate intake rather than excessive sodium loss.
• Amniotic fluid embolism: Amniotic fluid embolism is an acute, rare obstetric emergency that typically occurs during labor or immediately postpartum. The client’s current presentation in the first trimester does not indicate risk for this condition.
• Chorioamnionitis: Chorioamnionitis is an intrauterine infection usually associated with membrane rupture and labor. There is no report of infection, fever, or membrane compromise in this client. It is not an immediate risk at this stage of pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Monitor the client for hypertension: Epidural anesthesia commonly causes hypotension rather than hypertension due to sympathetic blockade and vasodilation. Continuous monitoring is essential, but the nurse focuses on identifying and managing hypotension.
B. Decrease the maintenance infusion rate of IV fluid: IV fluids are often administered before and during epidural placement to prevent hypotension. Reducing the infusion rate could worsen hypotension and compromise maternal and fetal perfusion.
C. Have protamine sulfate available at the bedside: Protamine sulfate is used to reverse heparin anticoagulation. It is not relevant to epidural administration and does not address the common risks associated with epidural anesthesia.
D. Reposition the client side-to-side each hour: Repositioning the client promotes maternal comfort, prevents pressure injury, and improves uteroplacental perfusion. Side-to-side positioning is recommended to avoid aortocaval compression and maintain adequate fetal oxygenation during labor.
Correct Answer is B
Explanation
A. Wear clothing with zippers instead of buttons: Clothing with zippers can be difficult for clients with Alzheimer’s disease who have fine motor skill deficits or cognitive impairment. Buttons or Velcro closures are typically easier for self-dressing and promote independence.
B. Place locks at the tops of exterior doors: Installing locks at higher levels prevents wandering, which is a common safety risk in clients with Alzheimer’s disease. This intervention helps reduce the risk of injury or elopement while allowing the client to move safely within supervised areas.
C. Encourage physical activity prior to bedtime: Physical activity close to bedtime can increase alertness and interfere with sleep. For clients with Alzheimer’s, promoting activity earlier in the day is more appropriate to maintain sleep-wake cycles and reduce nighttime agitation.
D. Replace the carpet with hardwood floors: Removing carpet may reduce tripping hazards in some cases, but hardwood floors can increase the risk of slipping and injury, especially for clients with balance or gait impairments. Non-slip flooring is preferred over bare hardwood for safety.
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