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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
(A) A client who smokes one pack of cigarettes per day:
While smoking is a significant risk factor for many health issues, including cardiovascular disease, it is not a direct contraindication for the use of an intrauterine device (IUD). However, smokers should be counseled about the risks of smoking and offered support to quit.
(B) A client who has a history of gallbladder disease:
A history of gallbladder disease does not contraindicate the use of an IUD. IUDs are primarily contraindicated in cases of active pelvic infection, certain uterine abnormalities, and confirmed pregnancy, but not gallbladder disease.
(C) A client who has a positive pregnancy test:
An IUD should not be inserted in a client who has a positive pregnancy test. Inserting an IUD during pregnancy can lead to complications such as infection, miscarriage, and preterm birth. It is crucial to confirm the absence of pregnancy before IUD insertion.
(D) A client who is nulliparous:
Being nulliparous (having never given birth) is not a contraindication for IUD use. IUDs can be safely used by nulliparous women, though some might have a slightly higher risk of expulsion or insertion-related discomfort compared to women who have given birth.
Correct Answer is B
Explanation
(a) "Wear an underwire bra between feedings."
Wearing an underwire bra between feedings can compress breast tissue and impede milk flow, increasing the risk of mastitis. This recommendation is incorrect and could contribute to the development of mastitis rather than preventing it.
(b) "You should use a breast pump if you plan to return to work."
Regularly expressing breast milk with a breast pump, especially if planning to return to work, helps maintain milk supply and prevents engorgement, which can lead to mastitis. This recommendation encourages appropriate breastfeeding practices to prevent mastitis.
(c) "Wash your nipples with soap and water daily."
While maintaining good breast hygiene is important, excessive washing with soap and water can strip the nipples of natural oils and increase the risk of dryness and cracking, which may predispose to mastitis. This recommendation is not the most effective strategy for preventing mastitis.
(d) "Cover your breasts immediately after feedings."
Covering the breasts immediately after feedings may trap moisture and promote bacterial growth, increasing the risk of mastitis. It is important to allow the breasts to air dry after feedings to prevent moisture buildup and promote healing of any cracked nipples. This recommendation is not appropriate for preventing mastitis.
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