A nurse is caring for a pregnant client diagnosed with hyperemesis gravidarum. Which nursing intervention should be the priority?
A 28-year-old woman at 10 weeks gestation presents to the emergency department with severe nausea and vomiting for the past week. She reports being unable to keep any food or fluids down and has lost 8 pounds since her last prenatal visit. Laboratory results show ketonuria and electrolyte imbalances.
1Encourage small, frequent meals with dry crackers
2Initiate intravenous fluid therapy with electrolyte replacement✓ 정답
3Administer oral antiemetic medications
4Provide emotional support and reassurance
해설
The priority intervention is IV fluid therapy with electrolyte replacement to correct dehydration and imbalances, as severe hyperemesis gravidarum can lead to maternal and fetal complications. Other options are supportive but not immediate priorities.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a patient with Hyperemesis Gravidarum (HG). HG is severe, persistent nausea and vomiting during pregnancy that leads to weight loss (>5% of pre-pregnancy weight), dehydration, electrolyte imbalances, and ketonuria. The core pathophysiology involves severe fluid and electrolyte depletion, which can threaten both maternal (e.g., Wernicke's encephalopathy from thiamine deficiency) and fetal well-being. The nursing priority follows the ABC (Airway, Breathing, Circulation) framework, addressing life-threatening circulatory volume deficit first.
Answer Rationale: Key Point! The patient presents with classic signs of severe dehydration and metabolic derangement: inability to tolerate oral intake, significant weight loss (8 lbs), and laboratory findings of ketonuria and electrolyte imbalances. Intravenous (IV) fluid therapy with electrolyte replacement is the immediate priority to restore intravascular volume, correct electrolyte abnormalities (like hypokalemia, hyponatremia), and resolve ketosis. This intervention directly addresses the most urgent, potentially life-threatening problem.
Distractor Analysis:
Watch out for confusion! Option ① (small, frequent meals) is a supportive measure for mild nausea/vomiting of pregnancy, not for severe, decompensated HG where oral intake is impossible. Recommending oral intake here is ineffective and delays critical treatment.
Option ③ (oral antiemetics) is incorrect because the patient cannot tolerate oral medications. In practice, antiemetics for HG are often given IV or rectally initially. Even if an antiemetic is needed, correcting fluid volume deficit takes precedence.
Option ④ (emotional support) is an important holistic nursing intervention but is not the physiological priority. Support is provided concurrently, but it does not address the acute metabolic crisis.
Related Concepts: Nursing care for HG extends beyond rehydration. Once stabilized, care includes gradual reintroduction of oral fluids/foods, administering IV thiamine (Vitamin B1) to prevent Wernicke's encephalopathy, ongoing nutritional assessment, and monitoring for complications like Mallory-Weiss tears from forceful vomiting.
Concept Summary
Concept
Key Points
Hyperemesis Gravidarum (HG)
Severe nausea/vomiting in pregnancy causing weight loss >5%, dehydration, ketosis, electrolyte imbalances. Differentiated from mild "morning sickness".
Priority Intervention
ABCs: Correct Circulation/Volume Deficit first with IV fluids and electrolytes.
Requires medical intervention (IV fluids, medications, possible hospitalization)
Minimal weight loss, no signs of dehydration
Significant weight loss (>5%), clinical and lab signs of dehydration/ketosis
Nursing focus: Education, comfort measures
Nursing focus: Acute stabilization, fluid/electrolyte replacement, prevention of complications
Anatomy, Physiology & Pharmacology PointsPathophysiology: The exact cause is multifactorial but involves high levels of hCG (Human Chorionic Gonadotropin) and estrogen. Severe vomiting leads to loss of gastric acid (H+ and Cl-), causing metabolic alkalosis initially. Prolonged starvation leads to fat breakdown and ketosis, which can cause a superimposed metabolic acidosis. Fluid & Electrolytes: IV fluids typically start with Isotonic crystalloids (e.g., Lactated Ringer's, Normal Saline) to expand volume. Potassium and other electrolytes are added based on lab results. Thiamine (100mg IV) is often added to the first bag of fluids to prevent neurological complications. Antiemetics: Common drugs include Doxylamine/Pyridoxine (Diclegin), Ondansetron (Zofran), and Metoclopramide (Reglan). Safety in pregnancy must be considered.
Memory TipsAcronym: DEHYD for HG priorities: Dehydration correction (IV Fluids) Electrolyte replacement Hydration status monitoring (I&O, weights) Your patient's ABCs come first! Diet advancement only AFTER rehydration
Think: "If they can't drink, you must sink an IV." Oral interventions fail when vomiting is this severe.
High-Frequency NCLEX Topics
NCLEX frequently tests prioritization in obstetric emergencies. HG is a classic example where you must choose the intervention that addresses the greatest physiological threat (dehydration/electrolyte imbalance) over comforting or less urgent measures. Expect questions on interpreting lab values (ketonuria, low K+) and knowing when hospitalization is required.
Watch Out for Question Variations!
* Shift from Symptom to Complication: "The nurse is monitoring a client with HG for which complication?" (Answer: Wernicke's encephalopathy, electrolyte imbalances).
* Shift from Intervention to Assessment: "Which assessment finding indicates the IV therapy is effective?" (Answer: Decreased ketonuria, increased urine output, stable weight).
* Medication Focus: "The physician orders IV thiamine for a client with HG. The nurse understands this is to prevent which condition?" (Answer: Wernicke's encephalopathy).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse in the OB triage area. Maria, 10 weeks pregnant, is brought in by her partner. She appears fatigued, with dry mucous membranes and poor skin turgor. She reports vomiting 10-15 times daily for a week and has not kept down even sips of water.
Nursing Intervention Strategy:
1Immediate Assessment & Stabilization (Priority)Apply oxygen if needed, establish two large-bore IV lines, draw labs (CBC, CMP, urine for ketones and specific gravity). Begin isotonic IV fluids (e.g., LR) at a rapid rate per protocol, then adjust to maintenance.
2Ongoing MonitoringMonitor vital signs frequently (watch for orthostatic hypotension). Implement strict I&O (Foley catheter may be needed initially). Weigh daily. Monitor for signs of fluid overload once rehydration begins.
3Medication AdministrationAdminister IV antiemetics (e.g., ondansetron) and IV thiamine as ordered. Add potassium to IV fluids once urine output is confirmed adequate.
4Nutritional & Supportive CareMaintain NPO (Nothing by Mouth) status initially. Once vomiting subsides, advance slowly: ice chips → clear liquids → bland, dry foods (BRAT diet). Provide quiet environment, oral care for dry mouth, and emotional support addressing anxiety.
5Education & Discharge PlanningTeach signs of recurrent dehydration. Discuss medication regimen for home. Refer to dietitian if needed.
Patient Safety and Precautions:
* Never force oral intake on a severely dehydrated, vomiting patient.
* Administer potassium only after confirming adequate renal function/urine output to prevent hyperkalemia.
* Monitor for Watch out for confusion! signs of fluid overload (crackles, shortness of breath) once the patient is rehydrated, especially if she has any underlying cardiac issues.
* Thiamine must be given before dextrose-containing fluids to prevent precipitating Wernicke's in a thiamine-deficient state.
Nursing Procedure & Medication FlowIV Therapy Initiation for HG:
1. Site Selection: Use a large, stable vein (e.g., forearm). Avoid areas of flexion.
2. Fluid Choice: Start with 1-2 liters of Lactated Ringer's (LR) or 0.9% Normal Saline (NS) over 2-4 hours to rapidly correct volume deficit.
3. Additives: After initial bolus and once labs are back, add potassium chloride (KCl) to bags as ordered. Maximum concentration and infusion rate for KCl is typically 10 mEq/hr via peripheral line (hospital policy varies). Always use an IV pump.
4. Thiamine Administration: Administer Thiamine 100mg IV slowly, often added to the first bag of IV fluids.
5. Rate Adjustment: Titrate to urine output >30 mL/hr and improvement in clinical signs. Switch to maintenance rate with dextrose-containing fluids (like D5 1/2 NS) once ketosis clears.
A Word from Your Senior Nurse
"In the whirlwind of an ED or OB unit, a patient with HG can seem 'just nauseous,' but never underestimate it. That ketonuria and weight loss are red flags waving at you. Your quick action to start IV fluids isn't just following an order—you're literally replenishing the foundation of life for both mom and baby. Remember, in nursing and on the NCLEX, physiology always trumps psychology in an acute crisis. Fix the broken pipe (dehydration) before you repaint the wall (provide reassurance). This mindset saves lives and earns you that RN license."
Hyperemesis Gravidarum — Severe, persistent nausea and vomiting during pregnancy leading to weight loss, dehydration, ketosis, and electrolyte imbalances.
Ketonuria — Presence of ketone bodies in the urine, indicating the body is breaking down fat for energy due to starvation/carbohydrate deficiency.
Intravenous (IV) Fluid Therapy — Administration of fluids directly into a vein to correct or prevent dehydration and electrolyte imbalances.
Wernicke's Encephalopathy — Acute neurological disorder caused by thiamine (Vitamin B1) deficiency, characterized by confusion, ataxia, and ophthalmoplegia; a risk in severe HG.
Metabolic Alkalosis — A condition where body fluids have excess base (alkali), often caused by loss of gastric acid from prolonged vomiting.