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. 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.

Correct Answer: C

Rationale: The correct answer is C: Being an adolescent. Adolescents are more prone to hyperemesis gravidarum due to several factors such as hormonal changes, increased stress, poor diet, and lack of prenatal care awareness. Being an adolescent increases the risk of complications during pregnancy leading to hyperemesis gravidarum. High levels of hCG (choice A) are a symptom rather than a cause of hyperemesis gravidarum. High blood pressure (choice B) and being underweight (choice D) are not directly linked to the development of hyperemesis gravidarum in adolescents.

Correct Answer: B

Rationale: The correct answer is B: Fluid volume deficit. When a pregnant client at 30 weeks experiences a gush of fluid from the vagina, it may indicate ruptured membranes leading to amniotic fluid leakage. This can lead to a decrease in amniotic fluid volume, potentially causing fluid volume deficit for both the mother and the fetus. This can result in complications such as preterm labor, infection, and fetal distress. The other choices are incorrect because: A: Infection is a potential risk due to the ruptured membranes, but the immediate concern is fluid volume deficit. C: Hypotension is not directly related to the scenario described. D: Decreased urinary output is not a typical immediate concern with ruptured membranes; rather, the focus should be on assessing for signs of fluid loss and ensuring hydration.

Correct Answer: B

Rationale: The correct answer is B. Getting baseline blood pressure and pulse and monitoring frequently during administration is crucial because hydralazine is a potent antihypertensive medication that can cause significant drops in blood pressure. Monitoring allows for early detection of hypotension or adverse reactions. A is incorrect because positioning the client supine with the head of the bed elevated 30 degrees is not specific to the administration of hydralazine for pre-eclampsia. C is incorrect because administering medication every 5 minutes until blood pressure is stabilized is not a standard protocol for hydralazine administration; it should be given as per physician's orders with appropriate monitoring. D is incorrect because informing the client about a positive direct Coombs test result is not relevant to the administration of hydralazine; this is more pertinent to medications that can cause hemolytic anemia.