A client who says she is about 6 weeks pregnant hears the baby's ...

[luminitza]

A client who says she is about 6 weeks pregnant hears the baby's heartbeat for the first time through a Doppler. Based on this data, which conclusion by the nurse is the most appropriate?
 
  A) The mother is at 8 to 12 weeks' gestation.
  B) The mother is at 16 weeks' gestation.
  C) The mother is at 4 to 8 weeks' gestation.
  D) The mother is at 20 weeks' gestation.

Question 2

An adult client and spouse are seen in an urgent care clinic. The client presents with a temperature of 102 F, complains of nausea, and has experienced vomiting and diarrhea for 12 hours.
 
  The nurse notes that the client's mucous membranes are pale and dry. Which action by the nurse is the most appropriate?
  A) Ask the spouse for more information.
  B) Assess for pedal edema.
  C) Assess skin turgor.
  D) Administer IV fluids.

[scrocafella]

Answer to Question 1

Answer: A

The ultrasonic Doppler device is the primary tool for assessing fetal heartbeat. It can detect fetal heartbeat, on average, at 8 to 12 weeks' gestation. If an ultrasonic Doppler is not available, a fetoscope may be used. The fetal heartbeat can be detected by fetoscope as early as week 16 and almost always by 19 or 20 weeks' gestation. The mother is not at 4 to 8 weeks' gestation because the Doppler device detected fetal heartbeat. If the mother has not yet heard the fetal heartbeat, she must be at less than 16 or 20 weeks' gestation.

Answer to Question 2

Answer: C

A client who presents with hyperthermia, vomiting, diarrhea, and pale dry mucous membranes requires assessment for dehydration. An appropriate action by the nurse is to assess the client's skin turgor, which can provide more support that the client is dehydrated and requires further intervention. Pedal edema would indicate fluid volume overload and not dehydration. Asking the spouse for more information will not provide adequate support for the treatment of dehydration. The nurse must further assess the client prior to administering IV fluids.