A nurse is assisting with the care of a client who is at 28 weeks of gestation.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

- Potential Condition: Placenta previa

- This condition is characterized by the placenta covering the cervix, which can lead to painless, bright red vaginal bleeding during the second or third trimester.

- Actions to Take:

1. Insert a large-bore peripheral IV catheter.

- This is a precautionary measure to ensure that there is immediate venous access for fluid and blood product administration if necessary.

2. Reinforce with the client to maintain bed rest.

- Limiting physical activity can help reduce the risk of further bleeding.

- Parameters to Monitor:

1. Vaginal bleeding

- Monitoring the amount, color, and frequency of bleeding is crucial to assess the ongoing blood loss and stability of the condition.

2. Fetal well-being

- Regular monitoring of fetal heart rate and movement is important to ensure the fetus is not in distress.

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Correct Answer is []

Explanation

- Potential Condition: Hyperemesis Gravidarum

Actions to take

Insert a peripheral venous access device:
Monitor and manage electrolyte values:

Parameters to monitor

Electrolyte values:
Urine ketones:

Rationale

- Potential Condition: Hyperemesis Gravidarum

- This condition is characterized by severe nausea and vomiting, leading to dehydration and nutrient loss, which can affect both the mother and fetus.

- Actions to Take:

1. Insert a peripheral venous access device:

- This will allow for the administration of IV fluids and medications to treat dehydration and correct electrolyte imbalances.

2. Monitor and manage electrolyte values:

- Given the client's low potassium levels, it's crucial to monitor and manage electrolytes to prevent complications.

- Parameters to Monitor:

1. Electrolyte values:

- Monitoring electrolyte levels is essential to ensure they are within normal ranges and to adjust IV fluid composition as needed.

2. Urine ketones:

- Positive urine ketones indicate that the body is using fat for energy due to inadequate glucose utilization, which is common in Hyperemesis Gravidarum. Monitoring will help assess the effectiveness of treatment and nutritional status.

A. Increase intake of fresh fruits. B. Restrict fluids to 1,000 mL/day. C. Eat dry, bland foods in the morning. D. Take an over-the-counter antacid.

Correct Answer is C

Explanation

A. Increasing fresh fruit intake may not help with morning sickness and could potentially exacerbate nausea if the fruits are acidic or hard to digest. Bland foods are generally better for managing nausea.
B. Restricting fluids is not recommended for managing morning sickness and can lead to dehydration. Adequate hydration is important, and fluids should be taken throughout the day.
C. Eating dry, bland foods in the morning, such as crackers or toast, can help manage morning sickness by settling the stomach before getting out of bed. This is a commonly recommended strategy for alleviating nausea during early pregnancy.
D. Over-the-counter antacids are not the first-line treatment for morning sickness and might not address the underlying cause of nausea. Dietary changes and other non-medication strategies are generally preferred for managing pregnancy-related nausea.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse is caring for a client who is at 9 weeks of gestation and reports nausea in the morning that continues until midafternoon. Which of the following actions should the nurse encourage the client to take?

Correct Answer is C

Explanation

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