A nurse is caring for a client who is pregnant.

Exhibit 1

Nurses' Notes

1000:

The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks.

1015:

IV fluids initiated. Prochlorperazine administered via intermittent IV bolus.

1100:

Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine.

1500:

Client tolerating fluids well. Ate four graham crackers without emesis. Has voided 300 mL of amber-colored urine.

Exhibit 2

Vital Signs

1000:

Temperature 36.8° C(98.2° F)

Heart rate 112/min

Respiratory rate 20/min

Blood pressure 100/65 mm Hg

SaO 97% on room air

1200:

Temperature 37° C(98.6° F)

Heart rate 102/min

Respiratory rate 20/min

Blood pressure 104/70 mm Hg

SaO2 98% on room air

1500:

Temperature 36.8° C(98.2° F)

Heart rate 90/min

Respiratory rate 18/min

Blood pressure 110/72 mm Hg

SaO2 97% on room air

For each discharge instruction, specify if each action is recommended or contraindicated for the client.

A. Heart rate 136/min is a normal finding for a newborn. The normal range of heart rate for a newborn is 100 to 160/min.

B. Nasal flaring is an abnormal finding for a newborn. Nasal flaring indicates respiratory distress and may be caused by conditions such as pneumonia, meconium aspiration, or congenital heart defects.

C. Transient strabismus is a normal finding for a newborn. Transient strabismus is a temporary misalignment of the eyes that occurs due to weak eye muscles and poor coordination. It usually resolves by 3 to 6 months of age.

D. Overlapping of sutures is a normal finding for a newborn. Overlapping of sutures is caused by molding of the skull during delivery and allows the head to fit through the birth canal. It usually resolves within a few days after birth.

Choice A reason:

Goal – oriented is the correct answer. Obsessive-compulsive personality disorder (OCPD) is a personality disorder characterized by a pattern of preoccupation with orderliness, perfectionism, and control. Individuals with OCPD tend to be highly organized, detail-oriented, and focused on achieving their goals. They often set strict standards for themselves and others and are driven by a strong need for perfection in all aspects of their lives.

Choice B reason

Provocative behaviour is not a characteristic commonly associated with obsessive-compulsive personality disorder (OCPD). In fact, individuals with OCPD tend to be more reserved, cautious, and serious in their interactions with others.

Choice C reason:

Lack of empathy While individuals with OCPD may struggle with interpersonal relationships due to their rigid standards and expectations, they typically do not lack empathy. They might find it challenging to understand and relate to emotions or perspectives that do not align with their own, but this is different from a complete lack of empathy, which is more commonly seen in certain other personality disorders.

Choice D reason.

Lability refers to emotional instability or rapid and extreme shifts in emotions. This is not a typical feature of obsessive-compulsive personality disorder (OCPD). Individuals with OCPD tend to be emotionally restrained and might have difficulty expressing emotions, rather than experiencing emotional lability.