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A nurse is collecting data from a client who has hyperemesis gravidarum.
Which of the following findings should the nurse anticipate?
- A. Decreased pulse rate.
- B. Increased fundal height.
- C. Proteinuria.
- D. Poor skin turgor.
Correct Answer: D
Rationale: Poor skin turgor is anticipated in hyperemesis gravidarum due to dehydration from persistent vomiting, a hallmark sign.
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Nurses' Notes Two weeks ago (32 weeks gestation): The client presented for a routine visit and denied vaginal bleeding or fluid leakage. Reports mild insomnia and occasional mild uterine cramping. 1+ nonpitting edema noted in bilateral feet and ankles. Weight recorded as 84 kg (185 lb). Today (0930): The client reports mild epigastric pain for the past three days and occasionally 'seeing spots' in her vision. 2+ nonpitting edema noted bilaterally in feet and ankles, and mild facial edema present. The client states her fingers 'swelled up overnight,' preventing her from wearing rings. Weight has increased to 86 kg (190 lb). Vital Signs: Blood pressure: 160/100 mm Hg, Heart rate: 88/min, Respiratory rate: 18/min, Temperature: 36.9°C (98.4°F), Oxygen saturation: 98% on room air. Diagnostic Results: Hemoglobin: 10 g/dL, Hematocrit: 35.9%, Platelet count: 95,000/mm³, AST: 200 U/L, ALT: 25 U/L, Total bilirubin: 1.8 mg/dL, Urine protein: 2+.
Which of the following findings should the nurse report to the primary health care provider?
- A. Platelet count
- B. Hematocrit value
- C. Nonstress test result
- D. Weight gain
- E. Edema
- F. Blood pressure
- G. BUN
Correct Answer: A,D,E,F
Rationale: Low platelets, rapid weight gain, edema, high BP, and proteinuria indicate preeclampsia, requiring immediate reporting.
A nurse in an obstetric clinic is caring for four clients.
The nurse should identify that an intrauterine device is contraindicated for which of the following clients?
- A. A client who has a history of gallbladder disease.
- B. A client who has a positive pregnancy test.
- C. A client who smokes one pack of cigarettes per day.
- D. A client who is nulliparous.
Correct Answer: B
Rationale: An IUD is contraindicated in clients with a positive pregnancy test because it can harm the developing fetus and lead to complications.
A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 6 to 8 hours.
Correct Answer: A
Rationale: Ambulation promotes venous return, preventing blood stasis and reducing thrombophlebitis risk after cesarean birth.
The nurse is collecting data from the client 24 hr later.
How should the nurse interpret the findings?
- A. Moderate lochia rubra: Sign of potential improvement.
- B. Client reports decreased level of pain: Sign of potential improvement.
- C. Temperature 38.4°C (101°F): Sign of potential worsening condition.
- D. WBC count 15,000/mm³ : Sign of potential worsening condition.
Correct Answer: C
Rationale: A temperature of 38.4°C (101°F) suggests a potential infection or inflammatory process, indicating a worsening condition.
The nurse should first address the client's blood pressure followed by the client's platelet count.
Which of the following options correctly prioritizes these actions?
- A. Blood pressure should be checked before platelet count.
- B. Platelet count is more important than blood pressure.
- C. Address both simultaneously.
- D. Ignore blood pressure.
Correct Answer: A
Rationale: Blood pressure should be checked first as it indicates immediate hemodynamic status, critical in acute settings, followed by platelet count for bleeding risk.