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) Incorrect- Elevated blood pressure is not a primary risk associated with hyperemesis gravidarum.
B) Incorrect- Leukopenia (low white blood cell count) is not a common consequence of hyperemesis gravidarum.
C) Correct - Hyperemesis gravidarum, severe nausea, and vomiting during pregnancy can lead to dehydration, which may affect amniotic fluid levels and result in hydramnios (excessive amniotic fluid).
D) Incorrect- Ketonuria (presence of ketones in the urine) is a possible consequence of excessive vomiting, but it's not the primary concern associated with hyperemesis gravidarum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect- The Papanicolaou (Pap) test is not used to determine ovulation status.
B) Incorrect-The Pap test is used to detect abnormal cervical cells and cervical cancer, not endometriosis.
C) Incorrect- The Pap test is not a procedure for removing uterine fibroids.
D) Correct - The primary purpose of the Pap test (Pap smear) is to detect abnormal cervical cells that could indicate the presence of cervical cancer or precancerous conditions.
Correct Answer is D
Explanation
Rationale:
A) Incorrect - Applying oxygen is not the priority action in the case of excessive vaginal bleeding and a boggy uterus. Oxygen therapy would be appropriate if there were signs of respiratory distress or decreased oxygen saturation, but it does not directly address the primary concern of uterine atony and bleeding.
B) Incorrect - Administering methylergonovine might be appropriate, but the priority is to address the uterine atony with fundal massage first. Fundal massage helps stimulate uterine contractions and control bleeding, which is crucial in this scenario.
C) Incorrect - Encouraging the client to empty her bladder is important, but it is not the first action to take in the case of excessive bleeding and uterine atony. Immediate intervention to control the bleeding takes precedence.
D) Correct - Initiating fundal massage is the priority action in this situation. A boggy uterus with excessive vaginal bleeding indicates uterine atony, which is a potentially life-threatening condition requiring immediate intervention to prevent further bleeding.
Fundal massage helps the uterus contract and control bleeding. Addressing uterine atony is critical to prevent further hemorrhage and stabilize the client's condition.
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