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 B

Explanation

(A) Apply elastic stockings before the client gets out of bed:
While elastic stockings can help prevent thrombophlebitis by promoting venous return and reducing the risk of blood pooling in the legs, applying them before the client gets out of bed may not be as effective as ambulation in preventing stasis and clot formation.

(B) Have the client ambulate as often as possible:
Ambulation helps prevent thrombophlebitis (inflammation of a vein with clot formation) by promoting blood circulation in the lower extremities. Moving the legs and walking encourage the calf muscles to contract, which aids in pushing blood back towards the heart, reducing the risk of blood stasis and clot formation.

(C) Apply warm, moist packs to the client's lower legs:
Applying warm, moist packs to the lower legs may provide comfort and relaxation, but it is not a primary measure for preventing thrombophlebitis. In fact, warm compresses may dilate blood vessels and potentially increase the risk of thrombosis in some cases.

(D) Administer NSAIDs every 4 to 6 hr:
Nonsteroidal anti-inflammatory drugs (NSAIDs) are not typically used for preventing thrombophlebitis. While NSAIDs can help manage pain and inflammation, they do not directly address the underlying mechanisms of thrombus formation or prevent blood stasis. Additionally, frequent administration of NSAIDs may carry risks of gastrointestinal bleeding and renal complications.

A. Weigh the newborn's wet diaper. B. Determine the newborn's respiratory rate. C. Auscultate the newborn's bowel sounds. D. Swaddle the newborn in blankets.

Correct Answer is B

Explanation

Answer: B. Determine the newborn's respiratory rate.

Rationale:

A. Weigh the newborn's wet diaper:
While monitoring fluid output is important in assessing hydration status and overall health, it is not the immediate priority. In the context of a newborn with neonatal abstinence syndrome (NAS), the respiratory status takes precedence, especially given that withdrawal can affect respiratory function.

B. Determine the newborn's respiratory rate:
Assessing the respiratory rate is crucial, as newborns with NAS may experience respiratory distress, including increased respiratory effort or apnea. Identifying any respiratory issues early allows for prompt intervention, which is vital for the newborn's safety and well-being. Ensuring adequate respiratory function is a priority in this population.

C. Auscultate the newborn's bowel sounds:
While assessing bowel sounds is relevant to monitoring gastrointestinal function and potential withdrawal symptoms, it is not the immediate priority. Changes in bowel sounds may occur due to the syndrome, but respiratory assessment should come first to ensure stability.

D. Swaddle the newborn in blankets:
Swaddling can provide comfort to a newborn with NAS; however, it is not the first action to take. Comfort measures are important, but they should follow critical assessments of the newborn's respiratory and overall clinical status to ensure safety.

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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?

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