A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum.
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
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 condition.
Urinary output 40 ml/hr
3+ ketones
Heart rate 100/min
WBC count 10000/mm3
Urine specific gravity 1050
Urine pH 5
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"A"}}
For the findings 24 hours later, the nurse should interpret them as follows:
Urinary output: 40 ml/hr
Interpretation: Sign of potential worsening condition
Explanation: A urinary output of 40 ml/hr is concerning and indicates potential dehydration. It is a sign of potential worsening of the client's condition, as it suggests inadequate fluid intake or ongoing fluid losses.
3+ ketones
Interpretation: Sign of potential worsening condition
Explanation: The presence of 3+ ketones in the urine suggests ongoing ketosis, which can occur in hyperemesis gravidarum due to starvation and the breakdown of fats for energy. It is a sign of potential worsening of the client's nutritional status.
Heart rate: 100/min
Interpretation: Sign of potential improvement
Explanation: A heart rate of 100/min is within the normal range. It can be interpreted as a sign of potential improvement, indicating that the client's cardiovascular system is maintaining an appropriate heart rate.
WBC count: 10,000/mm3
Interpretation: Unrelated to diagnosis
Explanation: The WBC count within the normal range (10,000/mm3) is unrelated to the diagnosis of hyperemesis gravidarum. It does not provide specific information about the client's condition in this context.
Urine specific gravity: 1.050
Interpretation: Sign of potential worsening condition
Explanation: A urine specific gravity of 1.050 is elevated and indicates concentrated urine. This finding is a sign of potential worsening of the client's dehydration status.
Urine pH: 5
Interpretation: Unrelated to diagnosis
Explanation: The urine pH of 5 is within the normal range and is unrelated to the diagnosis of hyperemesis gravidarum. It does not provide specific information about the client's condition in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a: The diaphragm should be used with a spermicide, not a vaginal lubricant. Spermicide is necessary to kill sperm and increase the effectiveness of the diaphragm.
b: The diaphragm can be inserted up to 6 hours before intercourse, making it a convenient option for contraception. It should be left in place for at least 6 hours after intercourse but not more than 24 hours to ensure effectiveness.
c: The diaphragm should not be removed 2 to 4 hours after intercourse. It must remain in place for at least 6 hours after intercourse to provide effective contraception.
d:Washing the diaphragm with detergent soap can damage the latex and increase the risk of deterioration. It should be washed with mild soap and water or with a special cleanser recommended by the healthcare provider.
Correct Answer is C
Explanation
A. Erythema toxicum: Erythema toxicum is a common and benign rash that appears in the first few days of life. It is characterized by pink or red blotches with a small, pimple-like elevation in the center. It is unrelated to a nuchal cord.
B. Periauricular papillomas: Periauricular papillomas are small skin tags or growths around the external ear. They are not typically associated with a nuchal cord and are unrelated to the newborn's delivery.
C. Facial petechiae: A nuchal cord occurs when the umbilical cord is wrapped around the baby's neck. During delivery, this can lead to pressure on the baby's head and face, resulting in small, pinpoint red or purple spots known as petechiae. These are often seen on the face and neck and are considered a transient and benign finding.
D. Telangiectatic nevi: Telangiectatic nevi, also known as "stork bites" or "angel kisses," are common vascular birthmarks. They are not specifically associated with a nuchal cord but rather represent dilated blood vessels near the surface of the skin.
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