A nurse is planning care for a client who is at 16 weeks of gestation and has hyperemesis gravidarum. Which of the following actions should the nurse anticipate taking?

Administer a calcium channel blocker.

Encourage foods that are low in proteins.

Monitor for glycosuria.

Monitor IV fluid therapy.

Answer and Explanation

The Correct Answer is D

A. Administer a calcium channel blocker. Calcium channel blockers are used primarily for hypertension, angina, and certain cardiac conditions. They are not standard treatment for hyperemesis gravidarum, which is managed with fluid replacement, antiemetics, and nutritional support to prevent dehydration and electrolyte imbalances.
B. Encourage foods that are low in proteins. Protein intake is essential for fetal growth and maternal health. Clients with hyperemesis gravidarum may tolerate small, frequent meals with bland, high-protein foods better than low-protein options. Avoiding protein is not a recommended intervention, as it does not reduce nausea and may contribute to nutritional deficiencies.
C. Monitor for glycosuria. While glycosuria can occur during pregnancy, it is more relevant in the assessment of gestational diabetes rather than hyperemesis gravidarum. The primary concern in hyperemesis gravidarum is dehydration and electrolyte imbalances rather than glycosuria.
D. Monitor IV fluid therapy. Clients with hyperemesis gravidarum often experience severe nausea and vomiting, leading to dehydration and electrolyte imbalances. IV fluid therapy is a critical intervention to restore hydration, correct electrolyte imbalances, and prevent complications such as ketonuria and hypotension.

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Correct Answer is B

Explanation

A. Prolonged PT/INR. Prolonged PT/INR may occur due to liver dysfunction or vitamin K deficiency, but it is not a direct result of pancreatitis. In pancreatitis, the liver is usually functioning normally unless there is concurrent liver disease.
B. Elevated lipase. Elevated lipase is a hallmark laboratory finding in pancreatitis. Lipase is an enzyme produced by the pancreas, and its levels rise significantly during episodes of pancreatitis, making it a key indicator in diagnosing the condition.
C. Elevated ammonia. Elevated ammonia levels are more commonly associated with liver dysfunction, such as hepatic encephalopathy, rather than pancreatitis. Pancreatitis primarily affects the digestive system, not the liver directly.
D. Decreased albumin. Decreased albumin can be seen in various conditions, including liver disease and malnutrition, but it is not a specific finding for pancreatitis. In acute pancreatitis, albumin levels may not be significantly affected, while chronic pancreatitis can lead to malabsorption and potentially lower albumin levels over time.

A. Apply intermittent suction for 30 seconds. B. Apply suction while inserting the catheter. C. Insert the catheter 10 cm (4 in). D. Wait 1 min between suctioning attempts.

Correct Answer is D

Explanation

A. Apply intermittent suction for 30 seconds. Suctioning should not exceed 10-15 seconds to minimize hypoxia and irritation to the airway. Continuous suctioning for 30 seconds can lead to discomfort and inadequate oxygenation.
B. Apply suction while inserting the catheter. Suction should not be applied while inserting the catheter. This technique can cause trauma to the mucosa and prevent effective suctioning. Suction should only be applied once the catheter is in the desired position.
C. Insert the catheter 10 cm (4 in). The appropriate insertion depth for nasopharyngeal suctioning is typically 12-15 cm (5-6 in) for adults. Inserting the catheter to the proper depth ensures effective suctioning of secretions while minimizing the risk of injury.
D. Wait 1 min between suctioning attempts. Waiting 1 minute between suctioning attempts is essential to allow for adequate oxygenation and to prevent trauma to the airway. This interval allows the client to recover and ensures the airway is not overly irritated or compromised.

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A nurse is planning care for a client who is at 16 weeks of gestation and has hyperemesis gravidarum. Which of the following actions should the nurse anticipate taking?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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