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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Applying triple antibiotic ointment on the baby’s umbilical cord is not typically recommended. The American Academy of Pediatrics advises against applying any antiseptic or antibiotic ointment to the umbilical cord stump in most cases.
Choice B rationale
Giving a newborn an immersion bath daily is not recommended. Newborns do not need daily baths, and excessive bathing can dry out their skin.
Choice C rationale
Swaddling a baby with their legs in an extended position is not recommended. This position can increase the risk of developmental dysplasia of the hip.
Choice D rationale
Offering a pacifier during naps or at bedtime can be part of a safe sleep routine for a newborn, once breastfeeding is well established.
Correct Answer is C
Explanation
Choice A rationale
Polyuria, or excessive urination, is not typically associated with the administration of an epidural block with an opioid analgesic.
Choice B rationale
Bilateral crackles in the lungs can be a sign of a respiratory condition such as pneumonia or heart failure. However, they are not a common side effect of an epidural block with an opioid analgesic.
Choice C rationale
Hypotension, or low blood pressure, is a known side effect of epidural analgesia. This is due to the blockade of the sympathetic chain, which can contribute to hypotension. Therefore, it is important for the nurse to monitor the client’s blood pressure during the administration of an epidural block with an opioid analgesic.
Choice D rationale
Hyperglycemia, or high blood sugar, is not typically a side effect of an epidural block with an opioid analgesic. Hyperglycemia is more commonly associated with conditions such as diabetes.
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