A nurse is caring for a 26-year-old female client who is at 14 weeks of gestation in the antepartum clinic.
Select the 3 findings that are unexpected.
Weight loss
Breast tenderness
Heart rate
Vomiting
Nasal congestion
Respiratory rate
Correct Answer : A,C,D
Choice A rationale: Weight loss
Weight loss during pregnancy, especially in the second trimester, is unexpected unless there is a medical condition such as hyperemesis gravidarum or other nutritional deficiencies. While mild weight fluctuations can occur, a consistent loss of weight rather than gradual gain suggests inadequate caloric intake due to persistent vomiting and dehydration.
Choice B rationale: Breast tenderness
Breast tenderness is a common and expected physiological change during pregnancy due to hormonal fluctuations, particularly increased estrogen and progesterone levels. It is not considered abnormal or unexpected at this stage of pregnancy.
Choice C rationale: Heart rate
A heart rate of 116/min is unexpected, as it is above the normal range for adults (typically 60–100/min). Pregnancy can cause a mild increase in heart rate, but tachycardia above 110/min may indicate dehydration, anemia, or electrolyte imbalance, all of which can stem from excessive vomiting and fluid loss.
Choice D rationale: Vomiting
While occasional nausea and vomiting (morning sickness) can be expected in early pregnancy, persistent vomiting up to eight times daily and symptoms of dehydration (dry mucosa, poor skin turgor, positive ketones in urine) raise concern for hyperemesis gravidarum, a more severe form of pregnancy-related nausea and vomiting.
Choice E rationale: Nasal congestion
Nasal congestion is common during pregnancy due to increased blood volume and vascular changes affecting the nasal mucosa. It is not unexpected and does not indicate a complication.
Choice F rationale: Respiratory rate
A respiratory rate of 20/min falls within the normal range for adults (typically 12–20/min), making it an expected finding.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Rapid plasma regain is not a standard laboratory test associated with hyperemesis gravidarum. Hyperemesis gravidarum involves significant fluid and electrolyte losses, but rapid plasma regain is not a specific indicator of this condition.
Choice B rationale
A urine culture is used to detect the presence of bacteria in the urine, typically to diagnose a urinary tract infection. While dehydration from hyperemesis gravidarum can increase the risk of a UTI, a urine culture is not a primary anticipated laboratory test for hyperemesis itself.
Choice C rationale
Prothrombin time (PT) is a blood test that measures how long it takes blood to clot. It is used to assess coagulation and is not directly related to the metabolic and electrolyte imbalances caused by hyperemesis gravidarum.
Choice D rationale
Urine ketones are a byproduct of fat breakdown for energy, which occurs when the body is not getting enough glucose. In hyperemesis gravidarum, persistent vomiting can lead to dehydration and starvation, forcing the body to break down fat for energy, resulting in ketonuria (ketones in the urine).
Correct Answer is ["A","B","C","E","F"]
Explanation
Choice A rationale
Hourly monitoring of deep tendon reflexes is crucial in clients receiving magnesium sulfate for severe preeclampsia. Magnesium sulfate acts as a central nervous system depressant, and diminished or absent deep tendon reflexes (normal range: 2+ to 4+) can indicate magnesium toxicity, necessitating immediate intervention to prevent serious complications like respiratory depression.
Choice B rationale
A urinary output of less than 30 mL per hour signals potential renal hypoperfusion, which can be exacerbated by severe preeclampsia and magnesium sulfate administration. Reduced kidney function can lead to the accumulation of magnesium, increasing the risk of toxicity. Prompt notification of the physician allows for timely adjustments in the treatment plan.
Choice C rationale
Calcium gluconate is the antidote for magnesium sulfate overdose. Having it readily available is essential in case the client exhibits signs of magnesium toxicity, such as respiratory depression, severe hypotension, or loss of reflexes. Prompt administration of calcium gluconate can reverse the effects of magnesium and prevent life-threatening complications.
Choice E rationale
Hourly monitoring of intake and output is vital to assess fluid balance and renal function in pregnant clients with severe preeclampsia receiving magnesium sulfate. Accurate measurement helps in detecting oliguria, a sign of worsening preeclampsia or magnesium toxicity, allowing for timely interventions to maintain adequate hydration and prevent complications.
Choice F rationale
Severe preeclampsia significantly impacts both renal and cardiac function due to widespread vasoconstriction and endothelial dysfunction. Close monitoring of these systems through laboratory tests (e.g., serum creatinine, BUN, electrolytes, ECG) and clinical assessments is essential to detect and manage potential complications such as acute kidney injury, heart failure, and arrhythmias.
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