A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the following findings should the nurse anticipate?

Increased fundal height

Poor skin turgor

Decreased pulse rate

Proteinuria

Answer and Explanation

The Correct Answer is B

(A) Increased fundal height:
Hyperemesis gravidarum, severe nausea, and vomiting during pregnancy, typically does not cause an increased fundal height. Fundal height may be normal or even decreased due to dehydration and weight loss.

(B) Poor skin turgor:
Poor skin turgor is a common finding in clients with hyperemesis gravidarum due to dehydration. Excessive vomiting leads to fluid loss and dehydration, resulting in poor skin elasticity and turgor.

(C) Decreased pulse rate:
Hyperemesis gravidarum usually results in dehydration and hypovolemia, which can lead to an increased heart rate rather than a decreased pulse rate. The body compensates for decreased fluid volume by increasing the heart rate to maintain adequate circulation.

(D) Proteinuria:
Proteinuria, the presence of abnormal amounts of protein in the urine, is not typically associated with hyperemesis gravidarum. Proteinuria can be a sign of kidney dysfunction or other medical conditions but is not directly related to severe nausea and vomiting during pregnancy.

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Correct Answer is A

Explanation

(A) Perform fundal massage:
Performing fundal massage is the highest priority action in this scenario. Complete saturation of the perineal pad within 30 minutes postpartum suggests excessive bleeding, which could indicate postpartum hemorrhage (PPH). Fundal massage helps to stimulate uterine contractions, which can aid in controlling bleeding by compressing blood vessels at the placental site. It is essential to assess the fundus for firmness and position and massage it if necessary, to prevent or manage PPH.

(B) Weigh the perineal pad:
Weighing the perineal pad can provide information about the amount of blood loss, but it is not the highest priority action at this moment. Fundal massage takes precedence to address the potential underlying cause of excessive bleeding.

(C) Apply oxygen by face mask:
While oxygen therapy may be indicated in certain situations, such as respiratory distress, it is not the highest priority in this scenario. The priority is to address the potential cause of excessive bleeding and prevent further complications associated with postpartum hemorrhage.

(D) Monitor urine output:
Monitoring urine output is an important aspect of postpartum care, but it is not the highest priority when the client is experiencing excessive bleeding. Addressing the potential cause of bleeding and preventing complications associated with postpartum hemorrhage take precedence.

A. "I should place my baby in the car seat at a 90-degree angle." B. "I will place a thick, soft pad behind my baby's back." C. "I can turn the car seat so it faces forward when my baby weighs 15 pounds." D. "I will place the retainer clip at the level of my baby's armpits

Correct Answer is D

Explanation

(a) "I should place my baby in the car seat at a 90-degree angle."
The baby should not be placed in the car seat at a 90-degree angle. Instead, the car seat should be reclined at a 30- to 45-degree angle to keep the baby's airway open and reduce the risk of suffocation.

(b) "I will place a thick, soft pad behind my baby's back."
Using a thick, soft pad behind the baby’s back is not recommended because it can interfere with the harness system and compromise the safety of the car seat. Only products that come with the car seat or are specifically designed for it should be used.

(c) "I can turn the car seat so it faces forward when my baby weighs 15 pounds."
The car seat should remain rear-facing until the child reaches the maximum weight or height limit allowed by the car seat manufacturer, which is typically around 2 years of age or longer. Turning the car seat to face forward at just 15 pounds is too early and not safe.

(d) "I will place the retainer clip at the level of my baby's armpits."
This is correct. The retainer clip should be positioned at the level of the baby's armpits. This placement ensures that the harness straps are properly positioned over the baby's shoulders and chest, providing optimal protection in the event of a crash.

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A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the following findings should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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