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 C

Explanation

Choice A rationale
Transient strabismus, or temporary misalignment of the eyes, is not typically a symptom observed in newborns exposed to opioids during pregnancy.
Choice B rationale
Mottling, or patchy skin color, is a common physical characteristic in newborns and is not specifically associated with opioid exposure during pregnancy.
Choice C rationale
A respiratory rate of 70/min is significantly higher than the normal range for a newborn, which is typically between 30 and 60 breaths per minute. This could be a sign of neonatal abstinence syndrome (NAS), a group of conditions caused by withdrawal from certain drugs that the newborn was exposed to in the womb.
Choice D rationale
Loose stools are not typically associated with opioid exposure during pregnancy.
Choice E rationale
Regurgitation, or spitting up, is common in newborns and is not specifically associated with opioid exposure during pregnancy.

A. The Plastibell will be removed 4 hours after the procedure. B. Yellow exudate will form at the surgical site in 24 hours. C. Notify the provider if the end of your baby’s penis appears dark red. D. Ensure the newborn’s diaper is snug.

Correct Answer is B

Explanation

Choice A rationale
The Plastibell is not removed 4 hours after the procedure. Instead, it remains on the penis until the foreskin falls off naturally in seven to 10 days.
Choice B rationale
Yellow exudate, which is a normal part of the healing process, will form at the surgical site within 24 hours after a Plastibell circumcision. Parents should be reassured that this is not a sign of infection.
Choice C rationale
The end of the baby’s penis may appear dark red immediately after the procedure, but this should improve within a few days. If the redness persists or worsens, parents should notify the provider.
Choice D rationale
Ensuring that the newborn’s diaper is snug is not specific to the Plastibell circumcision technique. While a snug diaper can help prevent leaks, it should not be so tight as to cause discomfort or restrict circulation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a term newborn who is 48 hours old. The mother has a history of opioid use during pregnancy and was prescribed methadone. Based on the findings 24 hours later, how should the nurse interpret the findings?

Correct Answer is C

Explanation

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?

Correct Answer is B

Explanation

A nurse is providing teaching to the guardians of a preterm newborn about temperature instability. Which of the following statements should the nurse make?

A nurse is caring for a client who is at 33 weeks of gestation. The nurse is assessing the client 24 hours later. How should the nurse interpret the findings?

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 assessing a patient who is 3 days postpartum. Which of the following findings should the nurse report to the provider?”

“A nurse is caring for a patient who is at 36 weeks of gestation and has a confirmed intrauterine fetal demise. Which of the following treatment options should the nurse anticipate the provider to discuss with the patient?”

A nurse is providing care to a client who is receiving an epidural block with an opioid analgesic. Which of the following findings should the nurse monitor as a potential adverse effect of the medication?