A nurse is caring for a client who is at 16 weeks of gestation and has hyperemesis gravidarum. Which of the following clinical findings should the nurse expect?
Constipation
Ketonuria
Hypertension
Polyhydramnios
The Correct Answer is B
A. Constipation is not directly associated with hyperemesis gravidarum.
B. Ketonuria occurs due to prolonged vomiting and starvation, indicating fat breakdown for energy.
C. Hypertension is unrelated to hyperemesis gravidarum.
D. Polyhydramnios refers to excessive amniotic fluid and is not a feature of hyperemesis gravidarum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
A. Supplement feedings with dextrose water – Dextrose water is not appropriate for newborn feeding. It lacks the necessary calories and nutrients and is not recommended for managing hyperbilirubinemia or hydration.
B. Administer intravenous dextrose – There is no evidence of hypoglycemia or need for IV fluids. This is not indicated based on the current assessment.
C. Obtain a total serum bilirubin – The yellow sclera and cephalohematoma (from vacuum-assisted birth) place the newborn at risk for hyperbilirubinemia. A serum bilirubin level is needed to assess severity.
D. Encourage breastfeeding every 2 hr – This promotes bilirubin excretion through stools and urine, which is essential in managing or preventing jaundice in newborns.
E. Prepare for an exchange transfusion – This is a treatment for severe hyperbilirubinemia or hemolytic disease, and is not indicated at this stage without bilirubin results.
F. Obtain blood cultures – The mother received appropriate intrapartum prophylaxis (2 doses of penicillin G) for GBS. The newborn shows no signs of sepsis (vital signs normal, active, feeding), so cultures are not indicated now.
Correct Answer is B
Explanation
A. Irrigating the insertion site with sterile water is not a standard part of the procedure.
B. Rh-negative clients are at risk for isoimmunization if fetal blood mixes with maternal blood during the procedure. Rh(D) immune globulin should be administered after the procedure to prevent Rh sensitization.
C. The client is usually positioned supine with a slight tilt to prevent vena cava compression, not strictly in a left lateral position.
D. Amniocentesis does not require the client to be NPO.
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