Difficulty: Medium
Average Score: 90%
Simulated
Passage / Scenario
A nurse in the emergency department is caring for a 19-year-old clientwho is at 18 weeks of gestation.
Exhibit 1
Nurses' Notes
Client presents with reports of nausea and vomiting for the past
several weeks, which has worsened in severity. Client states that
they have been unable to retain even clear fluids for the past 48
hr. Client reports no pain. Client reports a history of migraines
and asthma.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Rationale
Correct Answer: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale: The potential condition the client is most likely experiencing is ectopic pregnancy. The nurse should insert a peripher-all access device to administer medications and fluids, and perform daily fetal movement counts to monitor fetal well-being. The nurse should monitor urine ketones to assess for dehydration and Kleihauer-Betke values to evaluate for internal bleeding, which are common in ectopic pregnancies. Serum human chorionic gonadotropin (hCG) levels should also be monitored to track the progression of the pregnancy and ensure appropriate management.
Rationale: The potential condition the client is most likely experiencing is ectopic pregnancy. The nurse should insert a peripher-all access device to administer medications and fluids, and perform daily fetal movement counts to monitor fetal well-being. The nurse should monitor urine ketones to assess for dehydration and Kleihauer-Betke values to evaluate for internal bleeding, which are common in ectopic pregnancies. Serum human chorionic gonadotropin (hCG) levels should also be monitored to track the progression of the pregnancy and ensure appropriate management.