A nurse is caring for a client who has hyperemesis gravidarum. The nurse should identify that the client is at risk for which of the following conditions?
Elevated blood pressure
Leukopenia
Hydramnios
Ketonuria
The Correct Answer is C
A. Elevated blood pressure is typically associated with gestational hypertension or preeclampsia rather than hyperemesis gravidarum. In hyperemesis, the significant fluid loss through protracted vomiting more commonly leads to hypovolemia and a subsequent decrease in systemic blood pressure. While compensatory tachycardia may occur, hypertension is not a direct scientific expectation for this clinical condition.
B. Leukopenia, which is a decrease in the white blood cell count, is not a typical finding in clients suffering from hyperemesis gravidarum. Hemoconcentration caused by severe dehydration may actually result in a relative increase in various laboratory values, including hematocrit and occasionally white cell counts. There is no physiological mechanism within this disorder that causes the bone marrow suppression required for leukopenia.
C. Hydramnios, or excessive amniotic fluid volume, is generally associated with fetal anomalies or maternal diabetes rather than severe vomiting. Hyperemesis gravidarum is characterized by a state of maternal fluid volume deficit rather than an excess of amniotic fluid. In severe, untreated cases, maternal dehydration might actually lead to decreased placental perfusion and a potential reduction in amniotic fluid.
D. Ketonuria is a critical finding in hyperemesis gravidarum that indicates the body has shifted to an anaerobic metabolic state. Because the client cannot retain sufficient carbohydrates for energy, the body begins catabolizing adipose tissue to produce fuel, resulting in the accumulation of ketone bodies. The presence of these ketones in the urine confirms that the client is experiencing metabolic starvation and requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- Applying ointment to the skin during phototherapy is typically avoided as it can interfere with the effectiveness of the therapy.
B) Incorrect- Giving distilled water after feedings is not a typical intervention for phototherapy.
C) Correct - Repositioning the newborn every 2 to 3 hours is important to ensure adequate exposure of the skin to the phototherapy lights and to prevent pressure points.
D) Incorrect- Monitoring blood glucose levels is not a standard intervention during phototherapy unless there are specific indications for doing so.
Correct Answer is A
Explanation
A) Correct - Encouraging the client to void often is important, as a full bladder can increase discomfort and interfere with labor progress.
B) Incorrect- Remaining awake between contractions might not directly address pain management strategies.
C) Incorrect- Position changes can help with pain management, so minimizing them would not be appropriate.
D) Incorrect- The presence of a support person is often encouraged during labor, and there is no need to limit their time in the room.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today