A pregnant woman at 16 weeks' gestation is diagnosed with ...

[Bernana]

A pregnant woman at 16 weeks' gestation is diagnosed with hyperemesis gravidarum. She has been admitted to the floor from the Emergency Department. Which issue should receive priority for the nurse planning care?
 
  1. Fluid volume deficit
  2. Constipation
  3. Decreased pulse rate
  4. Knowledge deficit

Question 2

The breastfeeding postpartum client reports sore nipples to the nurse making a home visit. The intervention with the highest priority is:
 
  1. Infant positioning.
  2. Use of the breast shield.
  3. Use of breast pads.
  4. Type of soap used.

[CharlieArnold]

Answer to Question 1

1
Rationale:
1. The newly admitted client with hyperemesis gravidarum has been experiencing excessive vomiting, and is in a fluid volume deficit state. Because no pre-existing cardiac condition is present, the body has compensated for this fluid loss.
2. Constipation is more likely to be a problem in later pregnancy; however, if constipation were present, it would be a lower priority than would fluid volume deficit.
3. The pulse rate would be increased due to hypovolemia.
4. Knowledge deficit is a psychosocial need, and therefore will not be a top priority when providing care to this client.

Answer to Question 2

1
Rationale:
1. Infant positioning is a critical factor in nipple soreness. Changing positions alters the focus of greatest stress and promotes more complete breast emptying.
2. Use of the breast shield, use of breast pads, and type of soap used are not critical factors in alleviating nipple soreness.
3. Use of the breast shield, use of breast pads, and type of soap used are not critical factors in alleviating nipple soreness.
4. Use of the breast shield, use of breast pads, and type of soap used are not critical factors in alleviating nipple soreness.

[Bernana]

Gracias!

[okolip]

Thanks for the timely response, appreciate it