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 ["B","C","D","E"]
Explanation
Choice A rationale
Do not gain more than 25 pounds in pregnancy due to body image issues is incorrect. Gaining an appropriate amount of weight based on individual health and pregnancy needs is important, and it should not be restricted based on body image concerns.
Choice B rationale
Continue to take your prenatal vitamin every day is correct. Prenatal vitamins are essential in providing the necessary nutrients for both the mother and developing fetus, including folic acid, iron, and calcium.
Choice C rationale
Avoid alcohol, tobacco, and drugs is correct. These substances can have harmful effects on fetal development and should be avoided to ensure a healthy pregnancy.
Choice D rationale
Do not eat more than 12 ounces of low mercury fish each week is correct. While fish can be a good source of protein and omega-3 fatty acids, it's important to limit intake of fish that may contain higher levels of mercury to avoid potential harm to the fetus.
Choice E rationale
Increase caloric intake by 100-200 a day is correct. Pregnant teens need additional calories to support their own growth as well as that of the fetus, but the increase should be moderate and balanced with nutritional needs. .
Correct Answer is B
Explanation
Choice A rationale
Analysis of serum for tetanus antibodies is not an immediate action in acute injury scenarios. The priority is to provide immediate passive immunity.
Choice B rationale
Administration of tetanus immune globulin provides immediate passive immunity. This is crucial to prevent tetanus infection since the client has not been immunized since infancy.
Choice C rationale
Inducing labor to avoid tetanus in the fetus is not a recommended action. The focus should be on providing immediate protection to the mother to prevent infection.
Choice D rationale
Administration of tetanus immune globulin after delivery delays necessary immediate protection. The risk of tetanus infection is immediate, so prompt administration is required.
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