Nokea
The nurse is caring for a client with severe hyperemesis gravidarum. She is 10 weeks gestation and has a 10% weight loss. The client is being admitted for fluid and electrolyte replacement. The nurse is aware it is important to check which deficiency that puts the client at risk for Wernicke’s encephalopathy?
- A. Folic acid
- B. Vitamin D
- C. Thiamine
- D. Glucose
Correct Answer: C
Rationale: The correct answer is C: Thiamine. Thiamine deficiency can lead to Wernicke’s encephalopathy in patients with severe hyperemesis gravidarum due to poor nutrient absorption and inadequate dietary intake. This condition can cause neurological symptoms like confusion and ataxia. Folic acid (A) deficiency is common in pregnancy but is not directly related to Wernicke's encephalopathy. Vitamin D (B) deficiency is associated with bone health and immune function, not neurological symptoms. Glucose (D) is important for energy production but is not directly linked to Wernicke's encephalopathy. Checking thiamine levels is crucial to prevent neurological complications in this client.
You may also like to solve these questions
The nurse is caring for a client with severe hyperemesis gravidarum. She is 10 weeks gestation and has a 10% weight loss. The client is being admitted for fluid and electrolyte replacement. The nurse is aware it is important to check which deficiency that puts the client at risk for Wernicke’s encephalopathy?
- A. Folic acid
- B. Vitamin D
- C. Thiamine
- D. Glucose
Correct Answer: C
Rationale: The correct answer is C: Thiamine. In severe hyperemesis gravidarum, excessive vomiting can lead to thiamine deficiency, increasing the risk of Wernicke's encephalopathy, a neurological disorder. Thiamine is essential for the brain's energy metabolism. Without adequate thiamine, neurological symptoms such as confusion, memory issues, and ataxia can arise. Folic acid (choice A) is important for neural tube development but not directly related to Wernicke's encephalopathy. Vitamin D (choice B) deficiency can lead to various issues but is not associated with Wernicke's encephalopathy. Glucose (choice D) is a source of energy but does not directly influence thiamine deficiency and Wernicke's encephalopathy.
A nurse is caring for a client who is G1P0 and 36 weeks gestation who has been diagnosed with severe pre-eclampsia. Her blood pressure is 165/110. The physician has ordered hydralazine. The nurse knows she should do which of the following when administering this medication?
- A. Position the client supine with the head of the bed elevated 30 degrees.
- B. Get baseline blood pressure and pulse and monitor frequently during administration.
- C. Administer medication every 5 minutes until blood pressure is stabilized.
- D. Inform the client that this may cause a positive direct Coombs test result.
Correct Answer: B
Rationale: The correct answer is B. The nurse should get baseline blood pressure and pulse and monitor frequently during administration to assess the effectiveness and safety of the medication. This is crucial in managing severe pre-eclampsia.
Choice A is incorrect because the client should be positioned on her left side to prevent vena cava compression, not supine with the head of the bed elevated.
Choice C is incorrect because administering medication every 5 minutes without proper monitoring can lead to adverse effects like hypotension.
Choice D is incorrect because hydralazine does not cause a positive direct Coombs test result. It is important for the nurse to provide accurate information to the client.
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 labor and delivery nurse reviews a client’s prenatal records and notes that the client had a positive GBS culture at 27 weeks gestation. Based on current guidelines, what is the recommended plan?
- A. Send a GBS to the laboratory immediately
- B. Prepare to administer penicillin prophylactically
- C. Determine if a follow-up culture was done at 38 weeks gestation
- D. Determine if the patient received antibiotics for the positive strep
Correct Answer: B
Rationale: The correct answer is B: Prepare to administer penicillin prophylactically. This is recommended by current guidelines for clients with a positive GBS culture at 27 weeks gestation to prevent transmission to the newborn during delivery. Administering penicillin prophylactically during labor significantly reduces the risk of early-onset GBS disease in newborns.
A: Sending a GBS to the laboratory immediately is not necessary as the client's GBS status is already known.
C: Checking for a follow-up culture at 38 weeks gestation is not the recommended plan based on current guidelines.
D: Determining if the patient received antibiotics for the positive strep is not the immediate action needed; prophylactic antibiotics during labor are the standard of care.
The nurse is monitoring a woman with signs and symptoms of preterm labor. Which does the nurse include in the teaching plan?
- A. Importance of performing daily fetal movement counts
- B. Need to refrain from putting any objects in the vagina
- C. Need to take a daily stool softener
- D. The need to decrease fluid intake
Correct Answer: B
Rationale: The correct answer is B: Need to refrain from putting any objects in the vagina. This is important to prevent irritating the cervix and potentially triggering preterm labor. Putting objects in the vagina can introduce bacteria, leading to infection, which can increase the risk of preterm labor. Option A is important for monitoring fetal well-being but not directly related to preventing preterm labor. Option C is not relevant to preterm labor. Option D is incorrect as hydration is important in preventing preterm labor.