Nokea
A 17-year-old client has been admitted to the hospital for hyperemesis gravidarum. Which factor likely caused her condition?
- A. Having high levels of hCG
- B. Having high blood pressure
- C. Being an adolescent
- D. Being underweight
Correct Answer: C
Rationale: The correct answer is C: Being an adolescent. Adolescents are more prone to hyperemesis gravidarum due to several factors such as hormonal changes, increased stress, poor diet, and lack of prenatal care awareness. Being an adolescent increases the risk of complications during pregnancy leading to hyperemesis gravidarum. High levels of hCG (choice A) are a symptom rather than a cause of hyperemesis gravidarum. High blood pressure (choice B) and being underweight (choice D) are not directly linked to the development of hyperemesis gravidarum in adolescents.
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A client who is 30 weeks pregnant comes into the labor and delivery unit complaining of having a gush of fluid come from her vagina. Which complication is this client at risk for?
- A. Infection
- B. Fluid volume deficit
- C. Hypotension
- D. Decreased urinary output
Correct Answer: B
Rationale: The correct answer is B: Fluid volume deficit. When a pregnant client experiences a gush of fluid from the vagina at 30 weeks, it could indicate premature rupture of membranes (PROM) or preterm premature rupture of membranes (PPROM). This increases the risk of amniotic fluid leakage, leading to a decrease in the fluid surrounding the fetus. This can result in a fluid volume deficit for the fetus, potentially leading to complications such as fetal distress or preterm labor. In contrast, choices A, C, and D are less likely in this scenario. Infection (choice A) could be a risk later if the membranes are ruptured for an extended period. Hypotension (choice C) and decreased urinary output (choice D) are not directly related to the gush of fluid and are less likely in this immediate situation.
The nurse is caring for a client who is at 24 weeks gestation. Which assessment requires further intervention?
- A. Hemoglobin 11 and hematocrit 33
- B. Blood pressure of 130/80
- C. Patient has slight pedal swelling
- D. Urine dipstick for protein 3+
Correct Answer: D
Rationale: The correct answer is D because a urine dipstick showing protein of 3+ indicates significant proteinuria, a sign of preeclampsia in pregnancy. Preeclampsia can lead to serious complications for both the mother and the baby, such as eclampsia and fetal growth restriction. The nurse should further assess the client's blood pressure, perform additional tests for preeclampsia, and closely monitor the client's condition.
Choice A: Hemoglobin and hematocrit levels are within normal range for pregnancy and do not require immediate intervention.
Choice B: Blood pressure of 130/80 is slightly elevated but not concerning at this gestational age. Close monitoring is recommended.
Choice C: Slight pedal swelling is common in pregnancy due to fluid retention and usually does not indicate a serious issue.
During an assessment of a client at 32 weeks gestation with a history of congenital ventral septal defect, a nurse notes that the client is experiencing a nonproductive cough on minimal exertion. The nurse knows that this assessment finding may indicate which of the following?
- A. Orthopnea
- B. Pulmonary edema
- C. Anemia
- D. Decreased blood volume
Correct Answer: B
Rationale: The correct answer is B: Pulmonary edema. A nonproductive cough on minimal exertion in a pregnant client with a history of congenital ventral septal defect may indicate pulmonary edema. This condition occurs due to fluid accumulation in the lungs, leading to symptoms like coughing. The increased blood volume and pressure during pregnancy can exacerbate the client's existing heart condition, resulting in pulmonary edema. Orthopnea (choice A) is difficulty breathing when lying flat, not specifically related to coughing. Anemia (choice C) may cause fatigue and weakness but is not typically associated with a nonproductive cough. Decreased blood volume (choice D) would not directly lead to a nonproductive cough on minimal exertion.
The nurse is caring for a client with a suspected hydatidiform mole. Based on the diagnosis, what does the nurse anticipate? Select all that apply.
- A. Dark brown vaginal bleeding
- B. Strong fetal heart tones
- C. Fundal height larger than expected
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Strong fetal heart tones. In a hydatidiform mole, the pregnancy is abnormal and does not involve a fetus. Therefore, the absence of fetal heart tones is expected. Dark brown vaginal bleeding (A) is not specific to a hydatidiform mole. Fundal height larger than expected (C) and elevated blood pressure (D) are not typically associated with a hydatidiform mole.
The nurse is providing discharge instructions to a 28-year-old client who received methotrexate for an ectopic pregnancy. Which should the discharge instructions include?
- A. Make sure to take folic acid
- B. Make an appointment to see her provider in 6 weeks
- C. Flush the toilet twice after she urinates for the next 24 hours
- D. Resume all activity in 48 hours
Correct Answer: C
Rationale: The correct answer is C. Methotrexate is a chemotherapy agent that can be harmful to others if not properly eliminated from the body. Instructing the client to flush the toilet twice after urination for the next 24 hours helps to reduce the risk of exposing others to the medication through urine. This precaution is important to prevent potential harm to others.
Choices A, B, and D are incorrect:
A: Taking folic acid is generally recommended to reduce side effects of methotrexate but is not directly related to the safety of others.
B: While follow-up appointments are important, the immediate safety concern of methotrexate elimination is more critical.
D: Resuming all activity in 48 hours may not be appropriate depending on the individual's response to methotrexate and their recovery process.