A nurse is assisting in the care of a client who is at 18 weeks of gestation and reports nausea and vomiting daily that lasts throughout the day.
Which of the following findings indicates the client is experiencing a fluid imbalance?
Increased blood pressure.
Dry mucous membranes.
Elastic skin turgor.
Decreased heart rate.
The Correct Answer is B
Choice A rationale
Increased blood pressure is typically not a sign of fluid deficit, but rather can be a compensatory mechanism in early stages or indicate other conditions. In significant fluid imbalance due to nausea and vomiting, hypotension (decreased blood pressure) is more commonly observed as a result of reduced circulating volume.
Choice B rationale
Dry mucous membranes are a reliable indicator of dehydration and fluid volume deficit. When the body loses excessive fluids due to persistent nausea and vomiting, the oral mucosa becomes less hydrated and appears dry or tacky, reflecting reduced interstitial and intracellular fluid.
Choice C rationale
Elastic skin turgor indicates adequate hydration, as the skin quickly returns to its original position when pinched. In a client experiencing a fluid imbalance due to significant vomiting, one would expect to see decreased skin turgor, where the skin remains tented or slowly returns to normal.
Choice D rationale
Decreased heart rate is not a typical finding in fluid volume deficit. Rather, the body compensates for reduced circulating blood volume by increasing the heart rate (tachycardia) to maintain cardiac output and systemic perfusion, ensuring adequate oxygen delivery to tissues.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Light strokes on the abdomen with rhythmic breathing, known as effleurage, are a distraction technique during labor. This method stimulates large-diameter nerve fibers, competing with pain signals transmitted by smaller-diameter fibers, thus reducing the perception of pain. While helpful, it is not directly related to acupressure, which involves targeted pressure points.
Choice B rationale
Immersing oneself in warm water, or hydrotherapy, promotes muscle relaxation and reduces pain perception through buoyancy and heat transfer. The warmth increases blood flow and relaxes uterine muscles, providing comfort. This technique primarily acts on thermoreceptors and mechanoreceptors, facilitating systemic relaxation, distinct from the focused pressure of acupressure.
Choice C rationale
Placing tennis balls on the sacral area and leaning against them applies counterpressure, a technique effective for back labor. This external pressure can help alleviate pain by applying direct compression to the sacral nerves, which may be compressed by the fetal head. This method is a form of deep tissue manipulation, differing from the specific point stimulation of acupressure.
Choice D rationale
Acupressure involves applying pressure to specific anatomical points to alleviate pain and discomfort. Recognizing signals (e.g., contractions), responding (applying pressure), and relaxing (allowing the body's natural pain modulation) are key principles. This targets endogenous opioid release and influences neural pathways, promoting pain relief and often a sense of calm.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
? Rationale for Correct Answers
Diabetic diet is appropriate because the client meets diagnostic criteria for gestational diabetes mellitus (GDM). The 3-hour oral glucose tolerance test (OGTT) shows two or more elevated values:
- 1-hour: 220 mg/dL (normal <180 mg/dL)
- 2-hour: 165 mg/dL (normal <140 mg/dL)
- 3-hour: 142 mg/dL (normal 70–115 mg/dL)
According to the American Diabetes Association and ACOG, GDM is diagnosed when at least two values exceed thresholds. GDM increases risks for macrosomia, preeclampsia, and neonatal hypoglycemia, and requires dietary management as first-line therapy.
30 cal/kg/day is the recommended caloric intake for overweight or obese pregnant individuals with GDM. Caloric needs are based on pre-pregnancy weight:
- Normal BMI: 30–35 kcal/kg/day
- Overweight (BMI 25–29.9): 25 kcal/kg/day
- Obese (BMI ≥30): 30 kcal/kg/day is often used to balance fetal growth and glycemic control.
❌ Rationale for Incorrect Response 1 Options
Low-sodium diet is used for hypertension or preeclampsia, but this client has no signs of preeclampsia (e.g., proteinuria, headache, visual changes, epigastric pain).
High-protein diet is not a standard intervention for GDM and may worsen insulin resistance if not balanced.
Gluten-free diet is indicated for celiac disease, which is not present here.
❌ Rationale for Incorrect Response 2 Options
15–25 cal/kg/day are too low for pregnancy and may risk fetal growth restriction, especially in obese clients.
20 cal/kg/day is used in severe obesity or when caloric restriction is medically necessary, but not standard for GDM.
25 cal/kg/day is more appropriate for overweight (not obese) clients.
? Take-Home Points
- GDM is diagnosed with ≥2 abnormal values on a 3-hour OGTT.
- Dietary therapy is first-line management for GDM, focusing on controlled carbohydrate intake.
- Obese pregnant clients with GDM should receive ~30 kcal/kg/day based on pre-pregnancy weight.
- GDM increases risks for maternal and fetal complications and requires close monitoring.
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