A nurse is assisting with the admission of a client who has hyperemesis gravidarum.
Which of the following laboratory tests is the priority to complete?
Serum bilirubin.
Liver enzymes.
CBC.
Urinalysis for ketones.
The Correct Answer is D
Choice A rationale
Serum bilirubin is not the priority test for hyperemesis gravidarum. It is more relevant for assessing liver function and jaundice.
Choice B rationale
Liver enzymes may be elevated in hyperemesis gravidarum, but they are not the priority test. The primary concern is dehydration and electrolyte imbalance.
Choice C rationale
A CBC can provide information on the client’s overall health, but it is not the priority test for hyperemesis gravidarum. The focus should be on assessing hydration status.
Choice D rationale
Urinalysis for ketones is the priority test because it helps assess the severity of dehydration and malnutrition. The presence of ketones indicates that the body is breaking down fat for energy, which is a sign of inadequate caloric intake.
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Correct Answer is D
Explanation
Choice A rationale
A temperature of 37.8°C (100°F) 18 hours postpartum is slightly elevated but not necessarily indicative of a serious issue. It may require monitoring but is not the most urgent concern.
Choice B rationale
Abdominal pain during breastfeeding 8 hours postpartum is a common experience due to uterine contractions. While it may cause discomfort, it is not typically an urgent concern.
Choice C rationale
Not having a bowel movement 24 hours postpartum is not uncommon and does not usually require immediate attention. It can be addressed with dietary changes and other interventions.
Choice D rationale
Saturating one perineal pad over 2 hours 6 hours postpartum in a G5P4 client indicates a potential risk of postpartum hemorrhage. This is a more urgent concern that requires immediate assessment and intervention to prevent complications.
Correct Answer is A
Explanation
Choice A rationale
Retained placental fragments are a significant risk factor for postpartum hemorrhage. If parts of the placenta remain attached to the uterine wall, it can prevent the uterus from contracting properly, leading to excessive bleeding.
Choice B rationale
Breech presentation is not a direct risk factor for postpartum hemorrhage. While it can complicate delivery, it does not directly cause hemorrhage.
Choice C rationale
Urinary tract infection is not a risk factor for postpartum hemorrhage. It can cause other complications but does not directly lead to hemorrhage.
Choice D rationale
Oligohydramnios, or low amniotic fluid, is not a risk factor for postpartum hemorrhage. It can cause complications during pregnancy but does not directly lead to hemorrhage.