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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
If a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage after a cesarean birth, administering a 500 mL lactated Ringer’s IV bolus can help increase the client’s circulating volume and support her hemodynamic stability. This is often the first step in managing postpartum hemorrhage.
Choice B rationale
While evaluating urinary output is an important aspect of postoperative care, it would not directly address the issue of ongoing vaginal bleeding.
Choice C rationale
Applying an ice pack to the incision site can help reduce swelling and provide some pain relief, but it would not address the issue of vaginal bleeding.
Choice D rationale
Replacing the surgical dressing is part of routine postoperative care, but it would not directly address the issue of ongoing vaginal bleeding.
Correct Answer is C
Explanation
Choice A rationale
Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. Diminished deep tendon reflexes are not typically associated with NAS3.
Choice B rationale
The Moro reflex, also known as the startle reflex, is one of the many reflexes that babies are born with. An absent Moro reflex is not typically associated with NAS3.
Choice C rationale
Excessive crying is a common symptom of NAS. Babies with NAS are often irritable and hard to comfort.
Choice D rationale
Decreased muscle tone is not typically associated with NAS. In fact, babies with NAS often have increased muscle tone, which can result in tight muscle tone and difficulty relaxing muscles.
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