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
Explanation
A. The tape measure should be placed vertically, not horizontally, over the abdomen to measure fundal height accurately.
B. The client should be in a supine position, not left-lateral, during the measurement.
C. Fundal height is measured from the upper border of the symphysis pubis to the upper border of the uterine fundus.
D. A full bladder can distort the measurement, so the client should have an empty bladder before measuring fundal height.
Correct Answer is ["B","E"]
Explanation
A. Maternal Rh factor – The mother is O positive. Rh incompatibility is not a concern here because both mother and newborn are likely Rh positive, and no information suggests Rh incompatibility.
B. Gestational age – The newborn was born at 36 weeks and 4 days, which is considered late preterm and places the infant at increased risk for complications such as respiratory distress, jaundice, hypoglycemia, and feeding difficulties.
C. Apgar scores – Scores of 7 at 1 minute and 8 at 5 minutes are within the normal range and not indicative of distress or a complication risk.
D. Weight – A birth weight of 3,062 g (6 lb 12 oz) is appropriate for gestational age and not a risk factor.
E. Type of birth – Operative vaginal birth using a vacuum extractor increases the risk for complications like cephalohematoma, which is noted in the assessment (firm, edematous scalp area with ecchymosis not crossing suture lines). This can contribute to jaundice.
F. Length – A length of 48 cm (19 in) is appropriate for gestational age and not a risk factor.
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