A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum. Which of the following manifestations should the nurse expect?
Decreased BP.
WBC count 15,000/mm³ (5,000 to 15,000/mm³).
Pruritus.
Hemoglobin 18 g/dL (11 to 16 g/dL). .
The Correct Answer is A
Choice A rationale
"Decreased BP.”. This is correct because hyperemesis gravidarum can lead to dehydration, which in turn can cause hypotension (decreased blood pressure).
Choice B rationale
"WBC count 15,000/mm³ (5,000 to 15,000/mm³).”. This is incorrect because while WBC count can be elevated due to stress or infection, it is not a primary manifestation of hyperemesis gravidarum.
Choice C rationale
"Pruritus.”. This is incorrect because pruritus is not commonly associated with hyperemesis gravidarum. It is more likely related to other conditions like cholestasis of pregnancy.
Choice D rationale
"Hemoglobin 18 g/dL (11 to 16 g/dL).”. This is incorrect because an elevated hemoglobin level is not a direct manifestation of hyperemesis gravidarum, although dehydration can potentially concentrate blood components and slightly elevate hemoglobin.
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Correct Answer is A
Explanation
Choice A rationale
Respiratory rate of 10/min is a critical adverse effect, indicating potential respiratory depression due to magnesium sulfate, a serious and life-threatening condition requiring immediate intervention.
Choice B rationale
Urine output of 160 mL in 4 hours is lower than expected but not immediately life-threatening. It needs monitoring but is not as critical as respiratory rate.
Choice C rationale
Diaphoresis, or excessive sweating, can be a side effect of magnesium sulfate but is not life-threatening. It warrants attention but does not require immediate reporting.
Choice D rationale
Nausea is a common, less severe side effect of magnesium sulfate that does not indicate an urgent situation.
Correct Answer is D
Explanation
Choice A rationale
This statement is incorrect because a Papanicolaou test, or Pap smear, is not used for the removal of uterine fibroids. Fibroid removal typically involves surgical procedures like myomectomy.
Choice B rationale
This statement is incorrect because a Pap smear is not used to determine ovulation status. Ovulation can be monitored through methods like basal body temperature tracking or hormone assays.
Choice C rationale
This statement is incorrect because a Pap smear does not detect endometriosis. Endometriosis is usually diagnosed through laparoscopy or imaging studies like ultrasound or MRI.
Choice D rationale
This statement is correct because a Papanicolaou test is specifically designed to detect the presence of cervical cancer and precancerous changes in the cervical cells.