A nurse is caring for a 25-year-old client at 12 weeks gestation who has been admitted with hyperemesis gravidarum. The client has lost 10 pounds since her last prenatal visit and reports vomiting 8-10 times daily for the past week. Which nursing intervention should be the priority?
1Encourage small, frequent meals with dry crackers
2Administer prescribed antiemetic medication
3Provide emotional support and reassurance
4Initiate IV fluid replacement therapy✓ 정답
해설
IV fluid replacement is priority for severe hyperemesis with significant weight loss and frequent vomiting to correct dehydration and electrolyte imbalances. Other interventions (antiemetics, small meals, emotional support) are important but secondary to fluid resuscitation.
Core Nursing ExplanationKey Concept Analysis: This question assesses the nurse's ability to prioritize care for a patient with Hyperemesis Gravidarum (HG). HG is severe, persistent nausea and vomiting during pregnancy that leads to weight loss, dehydration, and electrolyte imbalances. The priority nursing intervention is always based on the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs. Physiological needs, especially fluid and electrolyte balance, take precedence over comfort, nutrition, or psychosocial needs when they are compromised.
Answer Rationale: The correct answer is ④ Initiate IV fluid replacement therapy. The patient's clinical data—12 weeks gestation, 10-pound weight loss, and vomiting 8-10 times daily—indicate Key Point!severe dehydration and a high risk for electrolyte imbalances (e.g., hypokalemia, metabolic alkalosis). IV fluids are the priority to restore intravascular volume, correct electrolyte disturbances, and prevent complications like renal failure or Wernicke's encephalopathy (from thiamine deficiency). This directly addresses the most immediate life-threatening physiological derangement.
Distractor Analysis:
Watch out for confusion!② Administer prescribed antiemetic medication: While antiemetics are a standard and important part of HG management, they are not the priority intervention in this acute, dehydrated state. Medication cannot be effectively absorbed or metabolized if the patient is severely volume-depleted. IV fluids must be started first to create a stable physiological environment.
Watch out for confusion!① Encourage small, frequent meals with dry crackers: This is excellent advice for managing routine morning sickness or mild nausea. However, for a patient vomiting this frequently and who has already lost significant weight, oral intake is likely not tolerated and does not address the urgent need for volume and electrolyte correction.
Watch out for confusion!③ Provide emotional support and reassurance: Psychosocial support is a crucial component of holistic nursing care for HG, as the condition is physically exhausting and emotionally distressing. However, according to Maslow and nursing prioritization frameworks, physiological stability (fluid/electrolyte balance) must be secured before higher-level psychosocial needs can be effectively addressed.
Related Concepts: The nursing process in HG involves Assessment (vital signs, orthostatic BP, skin turgor, mucous membranes, intake/output, lab values like BUN, creatinine, electrolytes), Nursing Diagnosis (e.g., Deficient Fluid Volume), Planning/Implementation (IV therapy, monitoring, antiemetics, nutritional support), and Evaluation (weight gain, decreased vomiting, normalized labs).
Concept Summary
Concept
Explanation
Hyperemesis Gravidarum (HG)
Severe nausea/vomiting in pregnancy causing >5% weight loss, dehydration, ketonuria. Different from mild "morning sickness."
Priority Setting (ABCs/Maslow)
Physiological needs (Fluid/Electrolyte balance) are always priority over safety, comfort, or psychosocial needs.
IV Fluid Therapy in HG
First-line treatment for dehydration. Often uses isotonic fluids (e.g., Lactated Ringer's, Normal Saline) with added electrolytes (potassium, vitamins like thiamine).
Mild nausea/vomiting with no signs of volume depletion.
Antiemetic Medication
Persistent vomiting after hydration is initiated, or for moderate symptoms to prevent progression.
As the first action before addressing fluid status in a dehydrated patient.
Dietary Modifications
First-line management for typical morning sickness; maintenance after acute HG is controlled.
During the acute, severe vomiting phase where oral intake is not feasible.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: HG is linked to high levels of pregnancy hormones (hCG, estrogen). Severe vomiting leads to loss of gastric acid (H+ and Cl- ions), resulting in Metabolic Alkalosis and Hypokalemia (from renal compensation and vomiting).
IV Fluids: Lactated Ringer's is often preferred over Normal Saline for initial resuscitation as it more closely mimics plasma electrolyte composition and reduces the risk of hyperchloremic metabolic acidosis.
Antiemetics: Common drugs include Doxylamine/Pyridoxine (Diclegin), Ondansetron (Zofran), and Metoclopramide (Reglan). Safety in pregnancy is a key consideration.
Memory Tips
Acronym: VIP for HG Priority: Volume (IV Fluids) first, then Intravenous medications (Antiemetics), then PO intake & Psychosocial support.
Think "Wet before Meds & Food": The patient must be rehydrated (wet) via IV before oral meds/food can be considered.
High-Frequency NCLEX Topics
NCLEX loves testing prioritization in maternal-health scenarios. Hyperemesis gravidarum is a classic example where you must choose the intervention that addresses the greatest physiological risk (dehydration/electrolyte imbalance) over other correct but less urgent actions. Always ask yourself: "What will kill or harm the patient first?"
Watch Out for Question Variations!
Shift from Intervention to Assessment: "Which finding should the nurse report immediately?" → Answer would be a sign of severe dehydration (e.g., heart rate 120 bpm, urine output <30 mL/hr, or serum potassium 3.0 mEq/L).
Shift to Patient Education: "Which statement by the client indicates understanding of discharge teaching?" → Correct answer would focus on dietary strategies for home management after the acute phase is resolved.
Shift to Medication Administration: "The nurse is preparing to administer IV potassium. Which action is priority?" → Answer would be to ensure the IV is patent and infusing well to prevent phlebitis or infiltration, as potassium is a vesicant.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on the antenatal unit. Ms. Jones, 25, is admitted at 12 weeks. She looks fatigued, her mucous membranes are dry, and she has poor skin turgor. She states, "I can't keep anything down, not even water." Her vital signs show: BP 100/60 (baseline 120/80), HR 110, RR 22. Her urine is dark and concentrated with ketones.
Nursing Intervention Strategy:
Immediate Action (Priority): Insert two large-bore IV catheters (18-20 gauge). Initiate IV fluid therapy as ordered (e.g., 1-2 liters of Lactated Ringer's over the first few hours). Add potassium chloride and multivitamins (especially thiamine) to the IV fluids as prescribed.
Assessment & Monitoring: Obtain daily weights (same scale, same time). Strictly monitor intake and output (I&O). Assess for signs of improving hydration (increased urine output, improved skin turgor, moist mucous membranes, stable vital signs). Monitor for signs of fluid overload (crackles in lungs, edema, shortness of breath).
Medication Administration: After IV fluids are running and the patient is more stable, administer prescribed IV antiemetics (e.g., ondansetron). Assess for effectiveness and side effects (e.g., headache, constipation with ondansetron).
Nutritional & Comfort Measures: Once vomiting subsides, initiate a clear liquid diet, progressing to bland, low-fat, small, frequent meals (BRAT diet: Bananas, Rice, Applesauce, Toast). Keep the environment clean and odor-free. Provide oral care frequently to relieve dryness and prevent stomatitis.
Psychosocial Support & Education: Acknowledge the difficulty of her experience. Educate her on the condition, treatment plan, and importance of follow-up. Discuss when to call the provider (e.g., if vomiting returns, signs of dehydration).
Patient Safety and Precautions:
IV Therapy Safety: Potassium must be diluted and infused via an infusion pump. Never give IV push potassium! Monitor the IV site closely for signs of infiltration or phlebitis.
Fall Risk: A dehydrated, weak patient is at high risk for falls. Implement fall precautions (call bell within reach, non-slip socks, assist with ambulation).
Fetal Monitoring: While not typically done at 12 weeks with external monitors, the nurse's priority is stabilizing the mother, as maternal stability is paramount for fetal well-being.
Nursing Procedure & Medication FlowIV Fluid Initiation for HG:
1. Verify provider's order (type of fluid, rate, additives).
2. Perform hand hygiene and don PPE.
3. Select appropriate IV catheter and site.
4. Insert IV catheter using aseptic technique.
5. Secure the catheter and apply a transparent dressing.
6. Connect IV tubing, prime, and label with date/time.
7. Program the infusion pump with the correct rate (e.g., 125 mL/hr).
8. Document: site appearance, catheter size, fluid type, rate, patient tolerance.
Antiemetic Administration (IV Ondansetron Example):
1. Check the order and the "Rights" of medication administration.
2. Reconstitute if needed. For IV push, administer slowly over 2-5 minutes.
3. Monitor for common side effects: headache, dizziness, constipation, QT prolongation (rare but serious).
4. Assess effectiveness: Ask patient to rate nausea on a scale of 0-10 before and after administration.
A Word from Your Senior Nurse
"Hyperemesis is so much more than 'bad morning sickness.' These patients are truly suffering and at real medical risk. In clinical practice, your keen assessment skills are everything. Noticing that subtle tachycardia or that small drop in blood pressure when they stand up tells you they're dry long before the lab results come back. When you see a question like this on the NCLEX, don't just pick the 'nursing' action—pick the life-saving action first. Remember: Fix the foundation (fluids and electrolytes) before you paint the walls (comfort and education). This mindset will guide you safely through countless clinical and test-taking situations."
Hyperemesis Gravidarum — Severe, persistent nausea and vomiting during pregnancy leading to weight loss (>5% of pre-pregnancy weight), dehydration, and electrolyte imbalances.
Metabolic Alkalosis — A condition where body fluids become too alkaline, often caused in HG by loss of gastric acid (H+ ions) from persistent vomiting.
Hypokalemia — Low serum potassium level (<3.5 mEq/L), a common electrolyte imbalance in HG due to vomiting and renal losses, causing muscle weakness, cardiac arrhythmias.
Wernicke's Encephalopathy — A neurological emergency caused by thiamine (Vitamin B1) deficiency, a risk in HG due to poor intake and vomiting. Symptoms include confusion, ataxia, and ophthalmoplegia.
Orthostatic Hypotension — A drop in blood pressure (systolic >20 mmHg or diastolic >10 mmHg) upon standing, a key assessment finding for dehydration and volume depletion.