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 A
Explanation
Choice A rationale
Iron needs significantly increase during pregnancy to support the increased blood volume, the formation of the placenta, and the growth of the fetus. Pregnant women often require additional iron to prevent anemia and ensure adequate oxygen transport to the baby.
Choice B rationale
While calcium requirements do increase during breastfeeding to support milk production, this statement is not directly related to the nutritional needs during pregnancy. The focus during pregnancy should be on adequate intake of nutrients that support both maternal and fetal health.
Choice C rationale
Vitamin E requirements do not decline during pregnancy. In fact, the need for antioxidants like vitamin E may increase to protect both the mother and developing fetus from oxidative stress.
Choice D rationale
While prenatal vitamins are important for meeting various nutritional needs during pregnancy, they do not always provide sufficient vitamin D. Some women may need additional supplementation based on their dietary intake, sun exposure, and individual health needs.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
The correct answer is:
A. Anticipated.
B. Nonessential.
C. Anticipated.
D. Anticipated.
E. Anticipated.
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