A nurse is caring for a 20-year-old female client in an antepartum unit. The client is a primigravida at 11 weeks of gestation and reports increased nausea and vomiting within the past week, with decreased appetite. The client denies abdominal or epigastric pain but notes weight loss of 2.8 kg (6.2 lb) over the past two weeks.
Complete the diagram by dragging from the choices below to specify:
- The condition the client is most likely experiencing.
- Two actions the nurse should take to address the condition.
- Two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale for correct condition: Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy, leading to dehydration, weight loss, and electrolyte imbalance. The client's significant weight loss of 2.8 kg (6.2 lb) in two weeks, increased nausea and vomiting, and decreased appetite are classic symptoms. The elevated BUN level suggests dehydration, which aligns with hyperemesis gravidarum. The absence of abdominal pain and the presence of facial pallor further support this condition.
Rationale for actions:
- Initiate IV fluid therapy to rehydrate the client and correct electrolyte imbalances caused by excessive vomiting.
- Administer ondansetron IV to control nausea and vomiting, improving the client's ability to tolerate oral intake.
Rationale for parameters:
- Weight should be monitored to assess the effectiveness of interventions and ensure the client is regaining or maintaining a healthy weight.
- Urine output indicates hydration status and kidney function, helping to evaluate the adequacy of fluid replacement.
Rationale for incorrect conditions:
- Cholecystitis: The client denies abdominal or epigastric pain, which is a key symptom of cholecystitis.
- Gestational diabetes mellitus: There is no mention of elevated blood glucose levels or other diabetic symptoms.
- Preeclampsia: The client's blood pressure is within normal range, and there are no signs of hypertension or proteinuria.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["July 27"]
Explanation
Step 1 is: October 20 + 7 days = October 27
Step 2 is: October 27 - 3 months = July 27
Step 3 is: July 27 + 1 year = July 27 next year
Final calculated answer: July 27.
Correct Answer is A
Explanation
Choice A rationale
Ambivalent feelings are common in early pregnancy due to hormonal changes and the significant life adjustments that accompany pregnancy. It is normal for pregnant women to experience mixed emotions as they adapt to the reality of impending parenthood.
Choice B rationale
Suggesting the client speak to her mother about these feelings may not be appropriate as it could dismiss the client's current feelings and needs. While family support is valuable, the nurse should first address the client's concerns directly.
Choice C rationale
Referring the client to a counselor may be necessary in some cases, but it is essential to first normalize the client's feelings. It helps in providing immediate reassurance and understanding before suggesting further intervention.
Choice D rationale
Telling the client "Don't worry, you will be fine once the baby is born" is dismissive and minimizes her current concerns. It is important to validate her feelings and provide supportive responses to help her cope with her emotions.
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