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 A

Explanation

A. "I will stop what I am doing and lie down." Stopping activity and resting helps reduce myocardial oxygen demand, which can relieve stable angina. Lying down also minimizes strain on the heart and decreases the risk of injury if the client becomes lightheaded.
B. "I will call the provider after taking one dose of nitroglycerin." Clients with stable angina should take one dose of sublingual nitroglycerin and wait five minutes. If pain persists after three doses taken five minutes apart, emergency medical services should be contacted instead of waiting to call the provider.
C. "I will hold my breath and bear down." The Valsalva maneuver can increase vagal tone, leading to bradycardia and decreased cardiac output, which may worsen angina rather than relieve it. This is not an appropriate response to chest pain.
D. "I will take two 325 milligram aspirin tablets at the same time." While aspirin is beneficial for preventing platelet aggregation, the usual recommended dose for acute chest pain is a single 160–325 mg tablet chewed immediately. Taking two full-dose aspirin tablets is unnecessary and may increase the risk of bleeding.

A. Cleanse skin eruptions with povidone-iodine. B. Avoid over-the-counter topical ointments. C. Administer an antibiotic medication. D. Place disposable thermometers in the client's room.

Correct Answer is A

Explanation

A. Cleanse skin eruptions with povidone-iodine. Cleaning the skin eruptions with a mild antiseptic like povidone-iodine can help reduce the risk of secondary bacterial infections and promote healing. Keeping the affected area clean is important in managing herpes simplex outbreaks.
B. Avoid over-the-counter topical ointments. Over-the-counter topical ointments are often recommended to help soothe the skin and alleviate discomfort during a herpes simplex outbreak. While some ointments may not be effective against the virus, it is not necessary to avoid all topical products.
C. Administer an antibiotic medication. Herpes simplex is caused by a virus, so antibiotics, which are effective against bacterial infections, would not be appropriate for treating this condition. Antiviral medications such as acyclovir or valacyclovir are indicated instead to help manage outbreaks.
D. Place disposable thermometers in the client's room. There is no specific need for disposable thermometers for a client with a herpes simplex outbreak. Standard infection control practices are sufficient, and there is no risk of contamination related to herpes that would require special thermometers.

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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?

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