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?

Dehydration

Hyperemesis Gravidarum

Gastroenteritis

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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Correct Answer is B, A, C, D, E

Explanation

Step 1 is to apply a warm cloth to the newborn’s heel for 5 to 10 minutes. Warming the heel improves blood flow to the area, making it easier to obtain a blood sample.

Step 2 is to clean the area with an antiseptic. This is to prevent infection.

Step 3 is to puncture the outer aspect of the newborn’s heel. The outer aspect of the heel is less sensitive and less likely to be injured by the lancet.

Step 4 is to collect the blood specimen. After the heel has been punctured, blood will start to flow out and can be collected.

Step 5 is to apply pressure to the site with a dry gauze pad. This is to stop the bleeding after the blood sample has been collected.

A. A client who has gestational diabetes mellitus B. A client who had a previous stillbirth C. A client who had a nonreactive nonstress test D. A client who has a previous classical incision

Correct Answer is D

Explanation

Choice A rationale
Gestational diabetes mellitus is not a contraindication for a contraction stress test. This condition affects how the mother’s body uses glucose (sugar) during pregnancy, but it does not interfere with the ability to perform a contraction stress test.
Choice B rationale
A previous stillbirth is not a contraindication for a contraction stress test. A stillbirth refers to the loss of a baby after 20 weeks of pregnancy. While this is a significant event, it does not prevent the mother from undergoing a contraction stress test in a subsequent pregnancy.
Choice C rationale
A nonreactive nonstress test is not a contraindication for a contraction stress test. A nonreactive nonstress test indicates that the baby’s heart rate does not speed up (or “react”) as it should when the baby moves. However, this result does not prevent the mother from undergoing a contraction stress test.
Choice D rationale
A previous classical incision is a contraindication for a contraction stress test. A classical incision refers to a vertical cut in the upper part of the uterus, which is typically used during a cesarean section. This type of incision increases the risk of uterine rupture, which can be life- threatening for both the mother and the baby. Therefore, a contraction stress test, which induces contractions, should not be performed due to the risk of uterine rupture.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to obtain a blood sample from a newborn’s heel. In what order should the nurse perform the procedure?

Correct Answer is B, A, C, D, E

Explanation

In a prenatal clinic, a nurse is caring for a group of clients. Which client should the nurse identify as having a contraindication for a contraction stress test?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a client following a tubal ligation procedure. Which statement by the client indicates an understanding of the teaching?

A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis. How should the nurse interpret the findings 24 hr later?

A nurse is educating the parents of a newborn about the Plastibell circumcision technique. Which piece of information should the nurse include in the teaching?

A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client in a hands-and-knee position. Which should the nurse ask to evaluate the effectiveness of this intervention?

A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?

A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which action should the nurse take?

A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.