A nurse in the emergency department is caring for a 19-year-old female client who is at 18 weeks of gestation. The client presents with reports of nausea and vomiting for the past several weeks, which has worsened in severity. The client states that she has been unable to retain even clear fluids for the past 48 hours. The client reports no pain but has a history of migraines and asthma.
Exhibits
The Correct Answer is []
• Hyperemesis gravidarum: The client’s symptoms such as severe nausea and vomiting, inability to retain clear fluids, and positive ketones in urinalysis suggest that she is most likely experiencing hyperemesis gravidarum, a pregnancy complication characterized by severe nausea, vomiting, weight loss, and electrolyte disturbance.
• Actions to take: The nurse should administer the prescribed antiemetic medication to help control the client’s nausea and vomiting. The nurse should also provide IV fluid replacement to correct the client’s dehydration and electrolyte imbalance.
• Parameters to monitor: The nurse should monitor the client’s urine output to assess her hydration status. The nurse should also monitor the client’s electrolyte levels, as electrolyte imbalances can occur with severe vomiting and dehydration. If the client’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While blood in the stool can be a sign of a problem in older children and adults, it is not uncommon for newborns to pass dark green or black stools (known as meconium) in the first few days after birth. This does not typically indicate a problem.
Choice B rationale
A newborn vomiting eight to ten times per day is a cause for concern. This could indicate a problem such as pyloric stenosis or gastroesophageal reflux disease, both of which require medical attention.
Choice C rationale
Cooling after each breastfeeding is not typically a sign of a problem. Newborns have immature temperature regulation systems, so slight variations in body temperature can occur.
Choice D rationale
Persistent crossing of the eyes in a newborn can be normal up to about 3 months of age. If it continues beyond this point, it may indicate a problem such as strabismus.
Correct Answer is A
Explanation
Choice A rationale
Maternal cytomegalovirus (CMV) infection is a serious health concern as it is associated with severe birth defects like sensori-neural hearing loss, impairment of cognitive development, and cerebral palsy. It is acquired by contact with body fluids and by vertical transmission from mother to fetus. Transmission can occur via the saliva and urine of the newborn, which is why this is the correct answer.
Choice B rationale
CMV does not require airborne precautions. It is not an airborne disease; it is spread through close, direct contact with a person infected with the virus.
Choice C rationale
CMV does not cause visible lesions on the mother’s genitalia. This is a characteristic of other sexually transmitted infections, not CMV2.
Choice D rationale
Mothers do not receive prophylactic treatment with acyclovir prior to delivery to prevent CMV2. Acyclovir is an antiviral medication used to treat herpes simplex virus infections, not CMV2.
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