Which of the following assessments would be suspicious for hyperemesis gravidarum?

Weight loss of more than 5% of pre-pregnancy body weight, higher than normal HCG levels

Light, pale straw colored urine

Moist mucous membranes

Increased skin turgor, lower than normal HCG

Answer and Explanation

The Correct Answer is A

A. Weight loss of more than 5% of pre-pregnancy body weight and higher than normal HCG levels are hallmark indicators of hyperemesis gravidarum. Severe, persistent nausea and vomiting can lead to significant weight loss, dehydration, and electrolyte imbalances. Elevated hCG levels, which are seen in multiple gestations or molar pregnancies, are associated with an increased risk of hyperemesis gravidarum. These findings together strongly suggest the diagnosis.

B. Light, pale straw-colored urine indicates adequate hydration and normal kidney function, which is inconsistent with hyperemesis gravidarum. In affected clients, dehydration usually results in dark, concentrated urine, often with decreased output. Relying on urine that appears normal would underestimate the severity of fluid loss in this condition.

C. Moist mucous membranes are a sign of proper hydration. Clients with hyperemesis gravidarum typically exhibit dry mucous membranes, reflecting fluid deficit. Moist mucous membranes would suggest the client is not experiencing the significant dehydration required for this diagnosis.

D. Increased skin turgor actually indicates good hydration or edema, whereas hyperemesis gravidarum causes decreased skin turgor due to fluid loss. Additionally, lower than normal hCG levels are not associated with hyperemesis gravidarum; nausea severity tends to correlate with higher hCG levels, so this finding contradicts the expected pathophysiology of the condition.

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Correct Answer is A

Explanation

A. Stadol (butorphanol) is an opioid agonist-antagonist that can cause respiratory depression in both mother and fetus if administered too rapidly or at the wrong time. Administering through the port farthest from the IV insertion site allows the medication to dilute in the bloodstream before reaching systemic circulation, reducing the risk of adverse effects.

B. Rapid IV fluid administration is not necessary and may cause fluid overload or exacerbate maternal hypotension. Standard IV maintenance rates are sufficient unless otherwise indicated.

C. Opioids should be administered between contractions, not during them, because giving the medication during a contraction can peak in the maternal bloodstream too quickly, increasing fetal exposure and risk of neonatal respiratory depression.

D. Stadol should be administered slowly over 3–5 minutes to prevent maternal adverse effects, including hypotension, respiratory depression, dizziness, and nausea. Rapid administration increases risk to both mother and fetus.

A. "I burp my daughter during and after the feeding and as needed." B. "Since reaching 2 weeks of age, I add rice cereal to my daughter's formula to ensure adequate nutrition." C. "I warm the bottle in my microwave oven." D. "I refrigerate any leftover formula for the next feeding."

Correct Answer is A

Explanation

A. Burping the infant during and after feeding is an important practice to release swallowed air, reduce discomfort, and prevent spitting up or gas. Burping as needed and during natural pauses in feeding demonstrates proper technique and understanding of infant feeding safety and comfort, indicating correct learning.

B. Adding rice cereal to formula at 2 weeks of age is not recommended. Early introduction of solids or thickened formula can increase the risk of aspiration, overfeeding, and gastrointestinal complications. Solid foods are generally introduced at about 4–6 months of age when the infant is developmentally ready.

C. Warming a bottle in a microwave oven is unsafe. Microwaves can cause uneven heating and “hot spots”, which may burn the infant’s mouth or throat. Safe warming methods include placing the bottle in warm water or using a bottle warmer.

D. Refrigerating leftover formula for the next feeding is inappropriate. Prepared formula should be used within 1–2 hours of feeding, and any leftover milk or formula from a feeding should be discarded to prevent bacterial growth and potential infection.

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Which of the following assessments would be suspicious for hyperemesis gravidarum?

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Correct Answer is A

Explanation

The nurse is evaluating the new mother's knowledge about appropriate infant bottle feeding techniques. Which statement by the client reassures the nurse that correct learning has taken place?

Correct Answer is A

Explanation

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