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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
While applying a spermicidal cream or jelly to the diaphragm is recommended to increase its effectiveness, the use of a vaginal lubricant is not typically recommended.
Choice B rationale
Washing the diaphragm with mild soap and warm water is recommended after each use. However, using detergent soap may cause irritation and is not typically recommended.
Choice C rationale

The diaphragm can be inserted up to 6 hours before intercourse. This allows for flexibility and spontaneity.
Choice D rationale
The diaphragm should be left in place for at least 6 hours after intercourse, not 2 to 4 hours. This is to ensure that all sperm are killed by the spermicide.

A. Administer a tocolytic medication B. Wrap the cord in a sterile towel and moisten with warm sterile normal saline C. Apply oxygen via facemask to the client D. Exert upward pressure on the presenting part

Correct Answer is D

Explanation

The correct answer is choiced. Exert upward pressure on the presenting part.

Choice A rationale:

Administering a tocolytic medication can help reduce uterine contractions, but it is not the immediate priority in this emergency situation. The primary goal is to relieve pressure on the umbilical cord to restore blood flow to the fetus.

Choice B rationale:

Wrapping the cord in a sterile towel moistened with warm sterile normal saline is important to prevent the cord from drying out and to maintain its temperature. However, this action does not address the immediate need to relieve pressure on the cord.

Choice C rationale:

Applying oxygen via facemask to the client can help improve maternal oxygenation, which indirectly benefits the fetus. However, it does not directly address the immediate issue of relieving pressure on the umbilical cord.

Choice D rationale:

Exerting upward pressure on the presenting part is the most critical action to take first.This maneuver helps to relieve pressure on the umbilical cord, thereby restoring blood flow and oxygen to the fetus, which is essential in this emergency situation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing instructions to a client who has chosen a diaphragm for birth control. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client who is in labor.The nurse notes that the umbilical cord is protruding from the client’s vagina. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is calculating the estimated date of birth using Nagele’s rule for a client who is pregnant and whose last menstrual cycle started June 21. What is the estimated date of delivery in the next year?

A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

A nurse is caring for a client who is in the third stage of labor and has a prescription for IV oxytocin administration following expulsion of the placenta. What clinical manifestations should the nurse expect as a therapeutic effect of the medication?

A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?

A nurse is caring for a client in labor who is experiencing abruptio placentae. What findings should the nurse expect?

A nurse in a clinic is caring for an adolescent patient who requests a prescription for birth control. Which of the following Questions should the nurse ask?

A nurse is admitting a patient to the birthing unit who reports her contractions started 1 hour ago. The nurse determines the patient is 80% effaced and 8 cm dilated.The nurse realizes that the patient is at risk for which of the following conditions?

A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hours old. The newborn has a Coombs positive result and a glucose level of 50 mg/dL (40 to 60 mg/dL). What should the nurse anticipate?