A nurse is assessing a client at 10 weeks of gestation who has been diagnosed with hyperemesis gravidarum. Which of the following manifestations should the nurse expect? (Select all that apply.)
Weight loss
Abdominal cramping
Severe vomiting
Electrolyte imbalance
Vaginal blood spotting
Correct Answer : A,C,D
A. Weight loss: Severe and prolonged nausea/vomiting leads to weight loss (>5% of pre-pregnancy weight). This is a key feature of hyperemesis gravidarum.
B. Abdominal cramping: Hyperemesis gravidarum does not cause abdominal cramping. Cramping is more associated with miscarriage, ectopic pregnancy, or gastrointestinal conditions.
C. Severe vomiting: Persistent, severe vomiting is the hallmark sign of hyperemesis gravidarum. It is much more severe than typical morning sickness and leads to dehydration and nutritional deficiencies.
D. Electrolyte imbalance: Prolonged vomiting leads to dehydration and loss of essential electrolytes (e.g., hypokalemia, hyponatremia, metabolic alkalosis).
E. Vaginal blood spotting: Hyperemesis gravidarum does not cause vaginal bleeding. Vaginal spotting could indicate a miscarriage or another obstetric complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I should schedule the test when the baby is usually active." The test relies on fetal movements to assess heart rate responses, so scheduling it when the baby is active improves accuracy.
B. "I will have to lie on my back during the test." Lying on the back (supine) can cause supine hypotensive syndrome by compressing the inferior vena cava. The client should lie in a semi-Fowler’s or left lateral position.
C. "My baby's heart rate will be monitored during the test." The NST assesses fetal heart rate patterns in response to movement, so monitoring the fetal heart rate is essential.
D. "It will take 20 to 30 minutes to complete the test." An NST typically lasts 20-30 minutes unless additional monitoring is needed due to a nonreactive result.
Correct Answer is D
Explanation
A. Increase the client's IV fluid infusion rate. While increasing IV fluids can improve placental perfusion, the priority intervention for late decelerations is repositioning the client to relieve uteroplacental insufficiency.
B. Palpate the client's uterus. Uterine palpation helps assess for tachysystole (excessive contractions), which could contribute to late decelerations. However, this is not the priority intervention.
C. Administer oxygen to the client. Oxygen administration (8-10 L/min via face mask) improves fetal oxygenation, but repositioning the client should be done first to relieve pressure on the placenta.
D. Turn the client onto her side. Repositioning the client to the left or right lateral position improves uteroplacental circulation and reduces compression of the inferior vena cava, increasing blood flow to the fetus.
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