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 A
Explanation
Choice A rationale
Lentils are a great source of dietary fiber. A cup of cooked lentils contains approximately 15.6 grams of fiber, which is higher than the other options listed.
Choice B rationale
A cup of cooked oatmeal contains about 4 grams of fiber, which is less than lentils.
Choice C rationale
A cup of raw cabbage contains about 2.2 grams of fiber, which is less than lentils.
Choice D rationale
A cup of cooked asparagus contains about 3.7 grams of fiber, which is less than lentils.
Correct Answer is D
Explanation
Choice A rationale
A previous delivery at 37 weeks gestation does not necessarily indicate a risk for preterm delivery. Preterm delivery is defined as delivery before 37 weeks of gestation.
Choice B rationale
A previous delivery of a newborn weighing 2.5 kg (5.5 lb) does not indicate a risk for preterm delivery. Low birth weight can be a result of preterm delivery, but it can also be due to other factors such as intrauterine growth restriction.
Choice C rationale
A previous reactive non-stress test does not indicate a risk for preterm delivery. A reactive non-stress test is a positive sign of fetal well-being.
Choice D rationale
A previous cervical cerclage indicates a risk for preterm delivery. Cervical cerclage is a procedure performed to prevent preterm birth in women with a history of preterm birth and who have a short cervix.
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