Nokea
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg
- B. Heart rate 98/min
- C. Urine output of 280 mL within 8 hr
- D. Urine negative for ketones
Correct Answer: D
Rationale: The correct answer is D: Urine negative for ketones. In hyperemesis gravidarum, excessive vomiting can lead to dehydration and ketosis. A negative urine ketone result indicates the client may not be adequately hydrated or receiving proper nutrition. This finding should be reported to the provider for further evaluation and intervention. Option A (Blood pressure 105/64 mm Hg) is within normal range for a pregnant woman. Option B (Heart rate 98/min) is slightly elevated but may be due to dehydration. Option C (Urine output of 280 mL within 8 hr) is inadequate and indicates poor fluid intake or excessive fluid loss. Reporting a negative urine ketone result is crucial to prevent further complications.
You may also like to solve these questions
A nurse is preparing to administer metronidazole 2 g PO to a client who has trichomoniasis. Available is metronidazole 250 mg tablets. How many tablets should the nurse administer?
- A. 8 tablets
- B. 4 Tablets
- C. 2 tablets
- D. 1 tablet
Correct Answer: A
Rationale: The correct answer is A: 8 tablets. To calculate the dose, divide the total dose by the dose per tablet. In this case, 2 g equals 2000 mg. Therefore, divide 2000 mg by 250 mg (dose per tablet), which equals 8 tablets. Each tablet contains 250 mg, so to reach the total dose of 2000 mg, the nurse needs to administer 8 tablets. Choice B (4 tablets) is incorrect because it would only provide 1000 mg, not the required 2000 mg. Choice C (2 tablets) would provide only 500 mg, not the required dose. Choice D (1 tablet) would provide only 250 mg, which is insufficient.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to increase my insulin doses during the first trimester.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will ensure that my bedtime snack is high in refined sugar.
Correct Answer: C
Rationale: Correct Answer: C - "I will continue taking my insulin if I experience nausea and vomiting."
Rationale: Nausea and vomiting can lead to decreased food intake, which may cause a drop in blood glucose levels. Continuing to take insulin as prescribed is crucial to prevent hypoglycemia and maintain stable blood glucose levels for both the mother and the baby. This demonstrates the client's understanding of the importance of insulin therapy during pregnancy.
Summary of other choices:
A: Increasing insulin doses during the first trimester is not recommended without healthcare provider guidance as insulin needs may vary.
B: Exercising with blood glucose levels of 250 or greater can be dangerous and may lead to further hyperglycemia.
D: Consuming a bedtime snack high in refined sugar can cause blood glucose spikes, which is not recommended for diabetes management during pregnancy.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. Palpating the uterus above the umbilicus 12 hours postpartum indicates uterine displacement due to a full bladder. A distended bladder can displace the uterus, leading to uterine atony and increased risk of postpartum hemorrhage. By assisting the client to empty their bladder, the nurse can help the uterus return to its proper position, reducing the risk of complications. Reassessing the client in 2 hours (A) does not address the immediate issue of bladder distention. Administering simethicone (B) is indicated for gas relief and not related to the palpated uterus. Instructing the client to lie on their right side (D) may be uncomfortable and does not address the underlying bladder distention.
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
- A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL (less than 95 mg/dL)
- B. A client who is at 34 weeks of gestation and reports epigastric pain
- C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL)
- D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria
Correct Answer: B
Rationale: The correct answer is B: A client who is at 34 weeks of gestation and reports epigastric pain. This client should be identified as the priority because epigastric pain in pregnancy can be a sign of preeclampsia, a serious condition that requires immediate attention to prevent maternal and fetal complications. Preeclampsia is characterized by high blood pressure and protein in the urine, and it can lead to seizures (eclampsia) if not managed promptly. The other clients have issues that are important but not as urgent as potential preeclampsia. Client A's blood glucose level is elevated but not critically high, Client C's hemoglobin level is slightly low but not acutely life-threatening, and Client D's symptoms of urinary frequency and dysuria are common in late pregnancy and do not indicate a medical emergency.
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
- A. I should empty my bladder before the procedure.
- B. I will be lying on my side during the procedure.
- C. I will be asleep during the procedure.
- D. I should start fasting 24 hours before the procedure.
Correct Answer: A
Rationale: The correct answer is A: "I should empty my bladder before the procedure." This statement indicates understanding because a full bladder can obstruct visualization during the amniocentesis. Choice B is incorrect because the client should be lying flat on their back during the procedure. Choice C is incorrect as local anesthesia is typically used, and the client is awake. Choice D is incorrect as fasting is not required for an amniocentesis.