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Mrs. W., blood type A+, rubella negative, hemoglobin 12 g, hematocrit 35%, is a primigravida in the first trimester. During her second prenatal visit she complains of being very tired, experiencing frequent urination, and a white vaginal discharge; she also states that her nausea and occasional vomiting persists. Based on these findings, the nurse would select which of the following nursing diagnoses?
a. Activity intolerance related to nutritional deprivation.
b.Alteration in elimination related to a possible infection
c. High risk for injury related to hematologic incompatibility
d. Alteration in physiologic responses related to pregnancy
Correct Answer: d. All of the data stated are within the normal expected range for a first trimester pregnancy. These factors are related to hormonal changes and the growing uterus.
The findings of fatigue, nausea and vomiting, and the hemoglobin and hematocrit count are all within the norm for a first trimester pregnancy.
Frequency of urination, from pressure of the growing uterus on the bladder, and a white vaginal discharge, from increased activity of cervical and vaginal cells, are all normal findings for a first trimester pregnancy.
There are no data to support this nursing diagnosis; a blood type of 0, or if the woman was Rh negative, would increase the risk for this type of injury to the fetus
Posted in: MCN NCLEX
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