A nurse is caring for a 28-year-old female client who is at 12 weeks of gestation and has been admitted to the emergency department with excessive vomiting for the past 48 hours. The client has lost 2.3 kg (5 lb) over 2 days.

Exhibits

The nurse is assessing the client 24 hours later. How should the nurse interpret the findings 24 hours later? For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening.

Urine pH 5.0

Urine specific gravity 1.050

3+ ketones

Urinary output 40 mL/hr

Heart rate 130/min

WBC count 10,000/mmt

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}

Urine pH 5.0: This is an improvement as the pH has increased from 4.4, moving closer to the normal range (4.6 to 8).
Urine specific gravity 1.050: This is a sign of potential worsening as the specific gravity has increased from 1.040, indicating possible dehydration.
3+ ketones: This is a sign of potential worsening as the presence of ketones has increased from 2+, indicating the body is breaking down fat for energy due to insufficient glucose.
Urinary output 40 mL/hr: This is an improvement as the urinary output has increased from 20 mL/hr, indicating better hydration.
Heart rate 130/min: This is a sign of potential worsening as the heart rate has increased from 128/min, possibly due to dehydration.
WBC count 10,000/mmt: This is unrelated to the diagnosis as it’s within the normal range (5,000 to 10,000/mm³) and doesn’t directly relate to the client’s symptoms of vomiting and dehydration.

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Correct Answer is A

Explanation

Choice A rationale
Irregular contractions of 10 to 20 seconds in duration that are not felt by the client during a nonstress test may indicate a need for further diagnostic testing. These could be Braxton Hicks contractions, which are normal, but if they become regular and increase in intensity, they could indicate preterm labor.
Choice B rationale
An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period is a normal finding on a nonstress test. This is known as a reactive nonstress test and indicates that the fetus is well-oxygenated.
Choice C rationale
No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period is a normal finding on a nonstress test. Late decelerations can indicate fetal hypoxia.
Choice D rationale
Three fetal movements perceived by the client in a 20-min testing period is a normal finding on a nonstress test. Fetal movement is a positive sign of fetal well-being.

A. Heart palpitations B. Bradycardia C. Hot flashes D. Shortness of breath

Correct Answer is A

Explanation

Choice A rationale
Terbutaline, a medication used to suppress preterm labor, can cause heart palpitations as an adverse effect. This is due to its action as a beta-adrenergic agonist, which can increase heart rate.
Choice B rationale

Bradycardia, or a slow heart rate, is not a typical adverse effect of terbutaline. Terbutaline is more likely to cause tachycardia, or a fast heart rate.
Choice C rationale
Hot flashes are not a common adverse effect of terbutaline. They are more commonly associated with hormonal changes, such as those that occur during menopause.
Choice D rationale
Shortness of breath is not a typical adverse effect of terbutaline. However, if it occurs, it could indicate a serious condition like pulmonary edema and should be reported immediately.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving terbutaline to treat preterm labor. What findings should the nurse identify as a potential adverse effect of this medication?

Correct Answer is A

Explanation

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