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 D
Explanation
Choice A rationale
While breast tenderness can be a side effect of oral contraceptives, it is not typically a sign of a serious problem. It may occur as the body adjusts to the hormones in the medication.
However, if the tenderness is severe or persists, the client should consult their healthcare provider.
Choice B rationale
Pain during intercourse is not typically associated with the use of oral contraceptives. If a client experiences this symptom, it may be due to other causes such as infection, inflammation, or certain medical conditions. It’s important to seek medical advice if this symptom occurs.
Choice C rationale
Unusual vaginal discharge can be a side effect of oral contraceptives, but it is not typically a sign of a serious problem. Changes in the color, consistency, or smell of vaginal discharge could indicate an infection or other medical condition and should be evaluated by a healthcare provider.
Choice D rationale
Severe abdominal pain is a symptom that the client should report to the provider immediately. This could be a sign of a serious problem such as a blood clot or liver disease. It’s important to seek immediate medical attention if this symptom occurs.
Correct Answer is C
Explanation
Choice A rationale
Moving the client onto their hands and knees is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Choice B rationale
Applying pressure to the client’s fundus is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Choice C rationale
This is the correct answer. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen. This maneuver helps to rotate the pelvis and open the sacrum to release the baby’s shoulder.
Choice D rationale
Pressing firmly on the client’s suprapubic area is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
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