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A nurse in the emergency department is caring for a 19-year-old patient who is at 18 weeks of gestation.

The patient presents with reports of nausea and vomiting for the past several weeks, which has worsened in severity. The patient states that they have been unable to retain even clear fluids for the past 48 hours.

The patient reports no pain.

The patient reports a history of migraines and asthma.

What condition is the patient most likely experiencing? What are two actions the nurse should take to address that condition, and what are two parameters the nurse should monitor to assess the patient’s progress?

A.

Dehydration

B.

Hyperemesis Gravidarum

C.

Gastroenteritis

D.

Food Poisoning

Answer and Explanation

The Correct Answer is B

Choice A rationale
Dehydration could be a result of prolonged nausea and vomiting, but it is not the primary condition. Dehydration is a complication, not the cause of the symptoms.
Choice B rationale
The patient is most likely experiencing Hyperemesis Gravidarum, a severe form of nausea and vomiting in pregnancy. It’s more extreme than the typical morning sickness experienced during pregnancy and can lead to weight loss and dehydration. The nurse should ensure the patient stays hydrated and monitor their weight. Antiemetic medications may be prescribed to help control the vomiting.
Choice C rationale
Gastroenteritis typically involves both vomiting and diarrhea, often accompanied by abdominal pain and fever. The patient’s symptoms do not indicate gastroenteritis.
Choice D rationale
Food poisoning is usually associated with consuming contaminated food or water and often involves symptoms such as abdominal cramps and diarrhea, which the patient does not report.
 


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Related Questions

Correct Answer is D

Explanation

Choice A rationale
While it’s true that there may not have been any indication of GBS in earlier prenatal testing, this does not explain why the test was not conducted earlier. GBS can come and go in the body, so a negative test earlier in pregnancy does not guarantee that the woman will still be GBS-negative later in pregnancy.
Choice B rationale
Even if previous deliveries were all negative for GBS, this does not mean that the woman will not have GBS in this pregnancy. GBS can come and go in the body, so each pregnancy is considered separately.
Choice C rationale
GBS is usually asymptomatic in adults, so the woman would not typically report any symptoms of GBS during her pregnancy. This does not explain why the test was not conducted earlier.
Choice D rationale
GBS testing is typically done between 35-37 weeks of gestation. This is because GBS can come and go in the body, so testing during this time frame gives the best prediction of whether or not the woman will have GBS at the time of delivery.

Correct Answer is B

Explanation

Choice A rationale
Limiting the length of breastfeeding to 5 minutes per breast is not typically recommended. It’s important for the baby to empty each breast completely, as the fat content of the milk increases as the breast empties.
Choice B rationale
Assessing the newborn’s latch while breastfeeding is crucial. A poor latch can cause sore nipples. The baby should take as much of the areola into their mouth as possible, with more areola showing at the top lip than the bottom.
Choice C rationale
Waiting 4 hours between daytime feedings is not typically recommended for a breastfeeding newborn. Newborns typically need to feed every 2-3 hours, or 8-12 times in 24 hours.
Choice D rationale
Offering supplemental formula between the newborn’s feedings can interfere with establishing a good milk supply and should be avoided unless medically necessary.

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