A nurse is assisting with the admission of a client who has hyperemesis gravidarum. Which of the following laboratory tests is the priority to complete?
Serum bilirubin
Liver enzymes
Urinalysis for ketones
CBC
The Correct Answer is C
(a) Serum bilirubin:
While serum bilirubin can provide useful information about liver function, it is not the most immediate concern for a client with hyperemesis gravidarum. This condition primarily involves severe nausea and vomiting, which can lead to dehydration and ketosis.
(b) Liver enzymes:
Liver enzymes can be elevated in hyperemesis gravidarum, but they are not the primary concern. The immediate priority is to assess the extent of dehydration and metabolic disturbances.
(c) Urinalysis for ketones:
This test is the priority because it helps determine the extent of dehydration and ketosis. In hyperemesis gravidarum, severe vomiting can lead to significant fluid and electrolyte imbalances and ketosis, which need to be identified and corrected promptly to prevent further complications.
(d) CBC:
A complete blood count (CBC) provides useful information about overall health and can identify anemia or infection, but it is not the priority for immediate assessment of hyperemesis gravidarum. The immediate need is to evaluate hydration status and ketosis, which is best done through urinalysis for ketones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
(A) Increased fundal height:
Hyperemesis gravidarum, severe nausea, and vomiting during pregnancy, typically does not cause an increased fundal height. Fundal height may be normal or even decreased due to dehydration and weight loss.
(B) Poor skin turgor:
Poor skin turgor is a common finding in clients with hyperemesis gravidarum due to dehydration. Excessive vomiting leads to fluid loss and dehydration, resulting in poor skin elasticity and turgor.
(C) Decreased pulse rate:
Hyperemesis gravidarum usually results in dehydration and hypovolemia, which can lead to an increased heart rate rather than a decreased pulse rate. The body compensates for decreased fluid volume by increasing the heart rate to maintain adequate circulation.
(D) Proteinuria:
Proteinuria, the presence of abnormal amounts of protein in the urine, is not typically associated with hyperemesis gravidarum. Proteinuria can be a sign of kidney dysfunction or other medical conditions but is not directly related to severe nausea and vomiting during pregnancy.
Correct Answer is B
Explanation
(A) Tell the client to apply hydrocortisone ointment to the affected area of the breast:
Hydrocortisone ointment is not appropriate for treating mastitis, which is an infection of the breast tissue. The primary treatments for mastitis include antibiotics, pain management, and supportive measures like warm compresses to relieve discomfort and promote milk flow.
(B) Suggest the client apply warm compresses to the affected breast:
Applying warm compresses to the affected breast can help relieve pain and promote milk flow, which can aid in resolving the infection. Warmth can help reduce inflammation and make breastfeeding or pumping less painful.
(C) Recommend the client avoid wearing a nursing bra until symptoms resolve:
Avoiding a nursing bra is not necessary. In fact, wearing a well-fitting and supportive nursing bra can help manage discomfort and support the breasts. It is important that the bra is not too tight to avoid further compression and blockage of milk ducts.
(D) Encourage the client to limit oral fluid intake to decrease milk production:
Limiting fluid intake is not recommended. Adequate hydration is important for overall health and maintaining milk supply. Reducing fluid intake does not effectively manage mastitis and can lead to dehydration.
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