A nurse is assessing a 28-year-old client at 10 weeks gestation who presents with severe nausea and vomiting. Which assessment finding would be most concerning and require immediate intervention?
1Vomiting 3-4 times per day with ability to retain some fluids
2Weight loss of 2 pounds over the past week
3Mild ketones present in urine
4Orthostatic hypotension with dizziness upon standing✓ 정답
해설
Orthostatic hypotension with dizziness indicates severe fluid volume depletion requiring immediate IV fluids to prevent maternal-fetal complications. Other findings (vomiting 3-4x/day, mild weight loss, mild ketonuria) are less urgent and manageable with supportive care.
Core Nursing ExplanationKey Concept Analysis: This question tests the nurse's ability to prioritize assessment findings in a pregnant client with Hyperemesis gravidarum (HG), a severe form of nausea and vomiting of pregnancy (NVP). The core theme is identifying signs of decompensation and fluid and electrolyte imbalance that pose an immediate threat to maternal and fetal well-being. While nausea and vomiting are common in early pregnancy, HG is characterized by severe, persistent vomiting leading to weight loss, dehydration, and electrolyte disturbances.
Answer Rationale: Key Point!Orthostatic hypotension (a drop in blood pressure upon standing) accompanied by dizziness is a classic, objective sign of significant hypovolemia (decreased blood volume). In pregnancy, this indicates severe dehydration that can compromise placental perfusion, leading to fetal distress. This finding requires immediate intervention, typically with intravenous (IV) fluid resuscitation, to restore circulating volume and prevent complications like acute kidney injury or Wernicke's encephalopathy (from thiamine deficiency).
Distractor Analysis:
Watch out for confusion! Option ①: Vomiting 3-4 times daily with some fluid retention is consistent with typical, non-severe morning sickness. It is concerning but not an immediate emergency.
Option ②: A 2-pound weight loss in one week is significant and indicates HG, but it is a subjective or cumulative finding. The immediate danger is determined by the client's current physiological state (e.g., vital signs, hydration status).
Option ③: Mild ketones in the urine (ketonuria) indicate the body is breaking down fat for energy due to inadequate caloric intake. This is a common finding in HG and signals the need for intervention, but it does not alone indicate the same level of acute circulatory compromise as orthostatic hypotension.
Related Concepts: The nursing priority follows the ABC (Airway, Breathing, Circulation) framework. Orthostatic hypotension directly threatens "Circulation." Management of HG focuses on correcting dehydration, electrolyte imbalances (especially hypokalemia, metabolic alkalosis), and providing nutritional support and antiemetic therapy.
Concept Summary
Concept
Description
Clinical Significance
Hyperemesis Gravidarum (HG)
Severe, persistent nausea/vomiting in pregnancy leading to weight loss (>5% of pre-pregnancy weight), dehydration, and electrolyte imbalance.
Distinguish from common morning sickness. Requires medical management to prevent maternal and fetal complications.
Orthostatic Hypotension
A drop in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg within 3 minutes of standing. Associated with dizziness, lightheadedness.
Key objective sign of hypovolemia/dehydration. A priority finding requiring immediate fluid resuscitation.
Ketonuria
Presence of ketones in the urine, indicating fat metabolism due to starvation or inadequate carbohydrate intake.
Supports diagnosis of HG and indicates nutritional deficit, but severity must be assessed in context with other findings.
Priority Setting
Using principles like ABCs and Maslow's Hierarchy of Needs to identify the most urgent client problem.
Physiological stability (e.g., circulation, fluid balance) always takes precedence over less acute issues.
Side-by-Side Comparison!
Assessment Finding
Typical Morning Sickness
Hyperemesis Gravidarum (Concerning)
Hyperemesis Gravidarum (EMERGENCY)
Nausea/Vomiting
Intermittent, often in morning, manageable.
Persistent, throughout day, interferes with oral intake.
Intractable, constant.
Weight Change
Minimal or no weight loss.
Weight loss >5% of pre-pregnancy weight.
Rapid, significant weight loss.
Hydration Status
Adequate. Good skin turgor, moist mucous membranes.
Signs of dehydration: dry mucous membranes, decreased skin turgor, dark urine.
Supportive care (dietary changes, small frequent meals).
Medical evaluation, may need oral/IV antiemetics, IV fluids.
Immediate hospitalization for IV fluids, electrolyte replacement, and possibly parenteral nutrition.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: HG is linked to high levels of pregnancy hormones like hCG (human chorionic gonadotropin) and estrogen. Severe vomiting leads to loss of gastric acid (H+ and Cl- ions), resulting in metabolic alkalosis and hypokalemia (from renal compensation). Fluid loss causes hypovolemia, reducing blood pressure and placental perfusion.
IV fluid of choice: Lactated Ringer's or 0.9% Normal Saline with potassium chloride (KCl) supplementation as needed.
Key Point! Thiamine (Vitamin B1) must be administered before or with dextrose-containing IV fluids in severely malnourished HG patients to prevent Wernicke's encephalopathy.
Memory Tips
RED FLAGS for HG: Use the mnemonic DIZZY KETO:
Dizziness (Orthostatic)
Intractable vomiting
Zero tolerance for fluids/food
Zero urine output (oliguria)
Yellow skin (jaundice - rare, severe complication)
Ketonuria (large)
Electrolyte imbalance (lab values)
Tachycardia
Over 5% weight loss
Think: "If they can't stand up, we need to step up." Orthostatic hypotension = Immediate action.
High-Frequency NCLEX Topics
This is a classic priority-setting and maternal assessment question. The NCLEX-RN loves to test your ability to differentiate between "expected" pregnancy discomforts and "complications" requiring intervention. Remember: Vital sign abnormalities (especially related to fluid volume) almost always trump other assessment data when determining priority.
Watch Out for Question Variations!
Symptom Identification → Priority Intervention: "The nurse identifies orthostatic hypotension in a client with HG. Which action should the nurse take first?" (Answer: Initiate IV fluid therapy as prescribed).
Lab Value Focus: "Which laboratory finding in a client with HG is most indicative of severe dehydration?" (Answer: Elevated BUN (Blood Urea Nitrogen) and creatinine, or Elevated hematocrit).
Medication Safety: "The nurse is preparing to administer dextrose IV to a client with severe HG. Which medication must be given prior to the dextrose?" (Answer: Thiamine).
Nursing Clinical Practice GuideClinical Scenario: You are a nurse in the OB triage unit. Maria, a 28-year-old G1P0 at 10 weeks, is brought in by her partner. She reports "can't keep anything down for 3 days," including water. She appears fatigued, with dry lips and pale skin.
Nursing Intervention Strategy:
Immediate Assessment (ABCs):
Vital Signs: Check BP and heart rate lying, sitting, and standing. Key Point! A rise in heart rate >20 bpm upon standing (orthostatic tachycardia) often precedes a significant BP drop and is also a sign of hypovolemia.
Hydration Status: Assess skin turgor, mucous membranes, capillary refill (>3 seconds is abnormal), and ask about urine output (color, amount).
Fetal Assessment: If >12 weeks, assess fetal heart tones with Doppler.
Priority Actions:
Establish IV access immediately and begin isotonic IV fluids (e.g., LR or NS) as prescribed.
Obtain STAT labs: CBC, BMP (Basic Metabolic Panel), urinalysis with ketones and specific gravity.
Administer prescribed IV antiemetics (e.g., ondansetron, metoclopramide).
Administer Thiamine (Vitamin B1) 100mg IV/IM before any dextrose-containing fluids if the client is severely malnourished.
Ongoing Care & Monitoring:
Strict I&O (Intake and Output), daily weights.
Monitor for complications: electrolyte reports (watch for hypokalemia < 3.5 mEq/L), signs of metabolic alkalosis (e.g., muscle twitching, confusion).
Provide oral care frequently to soothe dry, irritated mucous membranes.
Begin oral intake cautiously with clear liquids, advancing to small, frequent, bland, low-fat meals as tolerated.
Patient Safety and Precautions:
Fall Risk: Implement fall precautions (bed in low position, call bell within reach) for clients with dizziness/orthostasis.
Medication: IV metoclopramide can cause extrapyramidal side effects (EPS) like dystonia. Monitor closely.
Psychosocial: HG is physically and emotionally draining. Provide empathetic support, involve social work if needed for coping resources.
Nursing Procedure & Medication FlowManaging IV Fluids for HG:
Verify provider's order (e.g., "Lactated Ringer's 1 L IV bolus over 1 hour, then 125 mL/hr").
Use a large-bore IV catheter (e.g., 18-20 gauge) for rapid fluid administration if needed.
Calculate drip rate: Total mL ordered ÷ Total minutes × Drop factor (gtt/mL) = gtt/min.
Hang IV fluid and prime the line with thiamine if ordered concurrently to ensure it is administered first.
Monitor for fluid overload, especially in clients with cardiac history: assess lung sounds, respiratory rate, and jugular venous distension (JVD).
A Word from Your Senior Nurse
"Hyperemesis isn't just 'bad morning sickness.' It's a debilitating condition that can make a mother feel hopeless. As nurses, our sharp assessment skills are her first line of defense. Catching that orthostatic blood pressure change isn't just about passing a test—it's about recognizing a body crying out for help before it's too late. When you see a pregnant patient who is dizzy, think 'volume,' 'perfusion,' 'baby.' That clinical link will guide you to the right action every time. You are the advocate who ensures both mom and baby get through this safely."
Hyperemesis Gravidarum — Severe, persistent nausea and vomiting during pregnancy leading to weight loss, dehydration, and electrolyte imbalances.
Orthostatic Hypotension — A significant drop in blood pressure upon standing, indicating hypovolemia or dehydration.
Ketonuria — Presence of ketones in the urine, a sign the body is metabolizing fat due to inadequate caloric intake.
Hypovolemia — A decreased volume of circulating blood in the body, often due to fluid loss.
Metabolic Alkalosis — A condition where body fluids become too alkaline, often resulting from loss of stomach acid through vomiting.