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?

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.

Correct Answer: C

Rationale: The correct answer is C: Being an adolescent. Adolescents are at higher risk for hyperemesis gravidarum due to hormonal changes and inadequate nutritional intake. Adolescents often experience rapid growth and increased nutritional demands, leading to a higher susceptibility to conditions like hyperemesis gravidarum. High levels of hCG (A) are common in pregnancy and can contribute to nausea and vomiting but are not the primary cause of hyperemesis gravidarum. High blood pressure (B) is not directly related to hyperemesis gravidarum. Being underweight (D) may exacerbate the condition but is not the primary factor causing hyperemesis gravidarum in this case.

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.

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.

Correct Answer: C

Rationale: The correct answer is C: Obesity. Obesity is a significant risk factor for pre-eclampsia due to the increased strain on the cardiovascular system and potential inflammatory effects. It can lead to hypertension and vascular dysfunction, contributing to the development of pre-eclampsia. White race (A) is not a specific risk factor for pre-eclampsia. Multiparity (B) is a risk factor, but obesity has a higher association with pre-eclampsia. Infertility (D) is not a known risk factor for pre-eclampsia. In summary, obesity poses the highest risk due to its direct impact on cardiovascular health and inflammation.