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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
Calculation
400 mg ÷ 800 mg = 0.5 tablets.
The nurse should administer 0.5 tablets with each dose.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
? Rationale for Correct Answers
Hypoglycemia is defined in neonates as a blood glucose level <40–45 mg/dL. This newborn had a glucose of 35 mg/dL at 1 hour of life, which improved to 50 mg/dL after feeding. Clinical signs of neonatal hypoglycemia include jitteriness, abnormal cry, hypotonia, lethargy, poor feeding, and in severe cases, seizures. The newborn’s macrosomia (weight >4,000 g) suggests maternal diabetes or hyperglycemia, increasing the risk of neonatal hypoglycemia due to islet cell hyperplasia and subsequent insulin overproduction.
Jitteriness is a hallmark symptom of hypoglycemia. It is characterized by rhythmic tremors that can be stopped by holding the limb, distinguishing it from seizures. The resolution of symptoms after feeding and glucose normalization further supports hypoglycemia as the cause.
❌ Rationale for Incorrect Response 1 Options
Neonatal abstinence syndrome (NAS) typically presents later (24–72 hours post-birth) and includes high-pitched cry, tremors, hypertonia, poor feeding, and autonomic instability. There is no maternal history of opioid use or positive toxicology to support this.
Sepsis in neonates may present with temperature instability, lethargy, poor feeding, and respiratory distress. However, this newborn is alert, afebrile, and has stable vital signs, making sepsis unlikely.
Respiratory distress would involve signs such as nasal flaring, grunting, retractions, or tachypnea >60/min. This newborn has even, unlabored respirations and a normal rate of 45/min.
❌ Rationale for Incorrect Response 2 Options
High-pitched cry is more characteristic of NAS or neurologic irritation, not hypoglycemia.
Increased muscle tone is inconsistent with the hypotonia observed in this newborn and is more typical of NAS.
Nasal stuffiness is a nonspecific finding and not associated with hypoglycemia.
? Take-Home Points
- Neonatal hypoglycemia (<40–45 mg/dL) is common in large-for-gestational-age infants and presents early with jitteriness, hypotonia, and abnormal cry.
- Jitteriness in neonates should prompt immediate glucose evaluation to rule out hypoglycemia.
- NAS typically presents later and includes hypertonia, high-pitched cry, and feeding difficulties.
- Sepsis and respiratory distress must be ruled out with comprehensive assessment but are less likely with normal vitals and alertness.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.