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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?

A.

Decreased BP.

B.

WBC count 15,000/mm³ (5,000 to 15,000/mm³).

C.

Pruritus.

D.

Hemoglobin 18 g/dL (11 to 16 g/dL). .

Answer and Explanation

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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View Related questions

Correct Answer is ["B","F","G"]

Explanation

Choice A rationale:

Deep tendon reflexes of 1+ are considered normal for a postpartum client and do not typically require immediate follow-up. They indicate slight but definite muscle contraction with reinforcement.

Choice B rationale:

Lateral deviation of the uterus can indicate bladder distension, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. Immediate follow-up is necessary to address this issue.

Choice C rationale:

A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client and does not require immediate follow-up unless there are other symptoms of preeclampsia or hypertension.

Choice D rationale:

A pain rating of 3 on a scale of 0 to 10 is mild and is expected in the postpartum period. It does not require immediate follow-up unless the pain is severe or unrelieved.

Choice E rationale:

Soft breasts in the immediate postpartum period are normal as milk production has not yet fully begun. This does not require immediate follow-up.

Choice F rationale:

A soft uterine tone indicates uterine atony, which can lead to postpartum hemorrhage. This requires immediate follow-up and intervention to ensure the uterus is contracting properly.

Choice G rationale:

A large amount of lochia rubra can be a sign of postpartum hemorrhage. Immediate follow-up is necessary to assess and manage bleeding.

Choice H rationale:

Peripheral edema of 2+ in the bilateral lower extremities is common in postpartum clients due to fluid shifts and does not typically require immediate follow-up unless accompanied by other concerning symptoms.

Correct Answer is D

Explanation

Choice A rationale

A maternal age of 30 years is not a significant risk factor for preeclampsia. Preeclampsia is more common in very young mothers or those over the age of 35.

Choice B rationale

A prepregnancy BMI of 19 is within the normal range and is not considered a risk factor for preeclampsia, which is more commonly associated with higher BMI or obesity.

Choice C rationale

Being in the third pregnancy (multiparity) is not a strong risk factor for preeclampsia. The risk factors are more closely related to the individual's health conditions and first pregnancies.

Choice D rationale

Chronic hypertension is a well-known risk factor for preeclampsia as it indicates pre-existing cardiovascular issues that can predispose one to developing preeclampsia during preg

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