The nurse is assessing a client with hyperemesis gravidarum. What finding requires immediate intervention?

Correct Answer: C

Rationale: In the context of a client with hyperemesis gravidarum, a condition characterized by severe nausea, vomiting, weight loss, and electrolyte imbalances during pregnancy, the finding that requires immediate intervention is C) Dry mucous membranes and poor skin turgor. This finding indicates dehydration, a serious concern in pregnant women as it can lead to maternal and fetal complications. Dehydration can result in electrolyte imbalances, reduced blood volume, and decreased placental perfusion, putting both the mother and baby at risk. Immediate rehydration therapy is essential to prevent further complications. Option A) Urine output of 50 mL/hr is within the normal range for a pregnant woman, so it does not require immediate intervention. Option B) Weight loss of 5 pounds in 2 weeks, although concerning, is a common feature of hyperemesis gravidarum and may not warrant immediate intervention unless it is severe and accompanied by other critical symptoms. Option D) Nausea relieved by eating crackers is a common self-management strategy for nausea in pregnancy and does not indicate an immediate need for intervention. Educationally, this question highlights the importance of recognizing dehydration in pregnant women with hyperemesis gravidarum and the necessity of prompt intervention to prevent complications for both the mother and the fetus. Nurses need to be vigilant in assessing hydration status and responding promptly to signs of dehydration in this high-risk population.

Correct Answer: C

Rationale: In the context of monitoring a client with gestational hypertension, the symptom that requires immediate intervention is a severe headache and vision changes, marked by option C. This is because these signs can indicate a severe complication called preeclampsia, which is a serious condition characterized by high blood pressure and damage to other organs, such as the kidneys and liver. A weight gain of 1 pound in a week (option A) can be a common occurrence in pregnancy and may not necessarily warrant immediate intervention unless accompanied by other concerning symptoms. Slight swelling of the hands and feet (option B) is also common in pregnancy, especially in the third trimester, and is known as edema. While it should be monitored, it alone may not signify a need for immediate intervention. A blood pressure of 135/85 mmHg (option D) is elevated but not necessarily at a critical level requiring immediate intervention in this context. However, it should be closely monitored as it could indicate worsening hypertension or preeclampsia if accompanied by other symptoms. Educationally, this scenario highlights the importance of recognizing key symptoms that signify a worsening condition in gestational hypertension, such as severe headache and vision changes, and the need for prompt intervention to prevent maternal and fetal complications. Nurses must be vigilant in assessing and responding to these signs to ensure optimal outcomes for both the mother and newborn.

Correct Answer: B

Rationale: Rationale: The correct answer is B) It provides antibodies that protect against infection. Breastfeeding colostrum, the first milk produced after childbirth, is rich in antibodies such as immunoglobulin A, which plays a crucial role in protecting the newborn against infections. This early immune protection is vital for the baby's developing immune system, offering defense against a range of illnesses. Option A is incorrect because although colostrum is nutrient-dense, its main role is not to solely increase the baby's birth weight. Option C is incorrect as colostrum does not eliminate the need for formula supplementation; it complements and enhances the baby's nutrition. Option D is incorrect as while breastfeeding can promote bonding and reduce stress, it may not directly reduce maternal fatigue. In an educational context, it is essential for nurses to teach prenatal classes about the unique benefits of colostrum to encourage and support breastfeeding among new mothers. Understanding the specific advantages of colostrum can empower mothers to make informed choices for the health and well-being of their newborns.

Correct Answer: B

Rationale: If a dose is missed, it should be taken as soon as remembered and the next dose taken at the usual time. Choice A is incorrect because taking two doses at once may cause side effects. Choice C is incorrect because missing a dose does not require skipping the next dose. Choice D is incorrect because missing a dose does not typically require stopping the pills, but rather following instructions to compensate for the missed dose.

Correct Answer: B

Rationale: In the calendar method of contraception, women track their menstrual cycles to identify fertile days when they should avoid unprotected intercourse to prevent pregnancy. In this case, the patient had a range of 29 to 39 days for her menstrual cycles. Option B (day 10 through day 15) is the correct answer because it takes into account the potential variation in cycle length. This range is based on the assumption that ovulation typically occurs around 14 days before the start of the next menstrual period. By avoiding intercourse during these days, the likelihood of conception is lower. Option A (day 9 through day 19) is too broad and may not be accurate for this patient's specific cycle lengths. Option C (day 12 through day 16) does not consider the variability in cycle length, which could lead to inaccurate predictions of fertility. Option D (day 11 through day 28) includes days that are likely outside of the fertile window based on the patient's cycle lengths. Educationally, it is important for nurses to teach patients about the calendar method's limitations, such as cycle variability and the potential for inaccurate predictions. It is crucial to tailor the method to individual cycle patterns and provide clear instructions on tracking and interpreting menstrual cycles for effective contraception.