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 C
Explanation
Choice A rationale
History of methicillin-resistant Staphylococcus aureus (MRSA) is not directly related to the use of a cervical cap. The main concern with a cervical cap is infection, but MRSA history alone doesn't make it a contraindication for this form of contraception.
Choice B rationale
History of thrombophlebitis is more of a concern with hormonal contraceptives due to the risk of blood clots. A cervical cap does not involve hormones, so this condition is not a direct contraindication.
Choice C rationale
History of toxic shock syndrome (TSS) is a contraindication for the use of a cervical cap because the cap can increase the risk of developing TSS again. TSS is associated with prolonged use of barrier contraceptives, which can create an environment that fosters the growth of bacteria responsible for TSS.
Choice D rationale
Type 1 diabetes mellitus is not a direct contraindication for the use of a cervical cap. The concern with diabetes is often related to blood glucose control and potential infections, but it doesn't specifically contraindicate the use of cervical caps.
Correct Answer is A
Explanation
Choice A rationale
Each feeding should last between 20 and 30 minutes to ensure the baby gets enough nutrition and to facilitate bonding time.
Choice B rationale
Prepared formula should be used within 24 hours if stored in the refrigerator, not 5 days, to prevent bacterial growth and ensure the baby's safety.
Choice C rationale
Formula left at room temperature should not be refrigerated for reuse; it can develop bacteria that may harm the baby.
Choice D rationale
It is recommended to burp the baby multiple times during feeding to release swallowed air and prevent discomfort or spitting up.