A nurse is assessing a client at 8 weeks gestation who was admitted with hyperemesis gravidarum. Which assessment finding would be the priority concern for the nurse?
1Blood pressure of 110/70 mmHg
2Weight loss of 2 pounds since last visit
3Mild dehydration with dry mucous membranes
4Ketonuria with specific gravity of 1.035✓ 정답
해설
Ketonuria with high specific gravity indicates severe dehydration and ketosis from prolonged vomiting, requiring immediate intervention. Other findings are less severe or expected in hyperemesis gravidarum.
Core Nursing ExplanationKey Concept Analysis: This question assesses your ability to prioritize nursing concerns 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 core pathophysiology involves fluid volume deficit and metabolic acidosis (starvation ketosis) due to the body breaking down fat for energy when it cannot retain nutrients.
Answer Rationale: Option ④ is correct because it presents two critical, objective laboratory findings that together signal a severe, systemic complication requiring immediate intervention.
Ketonuria: The presence of ketones in the urine indicates the body is in a state of starvation, breaking down fat for energy. This is a sign of Key Point!metabolic imbalance and can lead to acidosis.
Specific gravity of 1.035: Normal urine specific gravity ranges from 1.005 to 1.030. A value of 1.035 indicates Key Point!significant concentration of the urine, which is a direct and sensitive marker of severe dehydration. The combination of ketonuria and high specific gravity paints a picture of a patient who is not just mildly dehydrated but is in a catabolic state with compromised renal function, posing risks to both the mother and the developing fetus.
Distractor Analysis:
Option ①: A blood pressure of 110/70 mmHg is within the normal range. In early dehydration, blood pressure may be maintained due to compensatory mechanisms. It is not a priority finding in this context.
Option ②: While a 2-pound weight loss is concerning and part of the diagnostic criteria for HG, it is a Watch out for confusion!chronic finding that reflects the problem over time. The priority in acute assessment is identifying findings that indicate an immediate threat to physiological stability, such as severe dehydration and ketosis.
Option ③: "Mild dehydration with dry mucous membranes" is a clinical sign of dehydration. However, the description "mild" indicates it is less severe. The objective data in option ④ (specific gravity 1.035) provides concrete evidence of a more severe state that requires urgent correction with IV fluids and electrolyte replacement.
Related Concepts: Nursing priorities follow the ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy. Here, the severe fluid volume deficit impacts circulation and metabolic function, making it the top priority. Management of HG focuses on IV rehydration, electrolyte replacement (especially potassium), antiemetic medications safe for pregnancy, and nutritional support.
Concept Summary
Concept
Explanation
Nursing Implication
Hyperemesis Gravidarum
Severe nausea/vomiting in pregnancy causing >5% weight loss, dehydration, ketosis.
Assess for signs of severe dehydration (high urine specific gravity, tachycardia, orthostatic hypotension) and ketonuria.
Ketonuria
Ketones in urine due to fat breakdown from starvation/insufficient carbohydrate intake.
Indicates metabolic imbalance. Priority finding requiring IV dextrose and calories to stop catabolism.
A high value (>1.030) is a key objective sign of dehydration.
Priority Setting
Use ABCs and potential for harm. Lab values indicating systemic instability trump mild clinical signs.
In HG, ketonuria + high specific gravity indicate immediate physiological threat > weight loss or mild dehydration.
Side-by-Side Comparison!
Assessment Finding
Indicates
Severity & Priority
Dry mucous membranes
Clinical sign of dehydration
Subjective/mild finding. Important to note, but not the top priority if isolated.
Weight loss (2 lbs)
Chronic nutritional deficit
Diagnostic for HG, but reflects past status. Address after acute fluid/electrolyte correction.
Ketonuria + SG 1.035
Severe dehydration & metabolic ketosis
High Priority! Objective data showing acute, systemic instability requiring immediate intervention (IV fluids).
Anatomy, Physiology & Pharmacology Points
Physiology: Prolonged vomiting leads to loss of H+ ions (hydrochloric acid) from the stomach, which can cause a metabolic alkalosis. However, the subsequent starvation from inability to eat leads to fat breakdown and production of ketoacids, which can cause a metabolic acidosis. The net effect is often a mixed acid-base disorder.
Electrolytes: Vomiting causes loss of potassium (K+), chloride (Cl-), and sodium (Na+). Hypokalemia is a major concern as it can cause cardiac arrhythmias.
Pharmacology (for context): First-line antiemetics for HG include Doxylamine/Pyridoxine (Diclegin), Ondansetron (Zofran), and Metoclopramide (Reglan). IV fluids with dextrose and electrolytes are the cornerstone of initial treatment.
Memory Tips
Acronym: For HG priorities, think "FED the mom":
Fluids (IV hydration),
Electrolytes (K+, Na+, Cl-),
Dextrose (to stop ketosis and provide calories).
Association: Specific Gravity >1.030 = Think "Very Concentrated" = Very Dehydrated.
Question Strategy: On NCLEX, when you see objective lab data (like ketones, specific gravity, electrolyte levels) paired with a subjective or chronic finding, the objective data indicating acute instability is almost always the higher priority.
High-Frequency NCLEX Topics
Hyperemesis Gravidarum is a Core topic in maternal nursing. The NCLEX loves to test:
1. Priority Assessment: Identifying the most urgent finding (as in this question).
2. Nursing Interventions: Knowing that IV fluid resuscitation with electrolytes is the first action.
3. Patient Education: Teaching about small, frequent, dry, bland meals (BRAT diet initially) and taking prenatal vitamins with food.
Watch Out for Question Variations!
From Symptom to Intervention: "The nurse notes ketonuria in a client with HG. Which action should the nurse take first?" (Answer: Initiate IV fluid therapy as prescribed).
Electrolyte Focus: "A client with HG is receiving IV fluids. Which electrolyte imbalance should the nurse monitor for most closely?" (Answer: Hypokalemia).
Medication Safety: "Which medication is safe for the nurse to administer to a client at 8 weeks gestation for nausea?" (Testing knowledge of pregnancy-safe antiemetics).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on the antepartum unit. M.S., a 28-year-old G1P0 at 8 weeks gestation, is admitted with a diagnosis of Hyperemesis Gravidarum. She reports vomiting 10-15 times per day for the past week, unable to keep any food or liquids down. She looks fatigued and has dry lips.
Nursing Intervention Strategy:
Immediate Assessment & Priority: Upon admission, your first actions are to assess vital signs (watch for tachycardia, orthostatic hypotension), establish IV access, and collect a urine sample for dipstick (checking for ketones and specific gravity). The lab finding of ketonuria and high specific gravity confirms severe dehydration and becomes your priority focus for intervention.
Collaborative Care: You will initiate IV therapy as prescribed—typically Lactated Ringer's (LR) or Normal Saline (NS) with added potassium chloride (KCl) and dextrose. You monitor the infusion rate closely to correct dehydration without causing fluid overload.
Ongoing Monitoring: Strict intake and output (I&O), daily weights, reassessment of mucous membranes and skin turgor. Monitor for signs of improving hydration: urine output >30 mL/hr, decreasing specific gravity, resolution of ketonuria.
Nutritional Support & Education: Once vomiting is controlled, begin with clear liquids, advancing to small, frequent, bland, low-fat meals. Administer prescribed antiemetics before meals. Educate the patient on taking prenatal vitamins with food at night.
Patient Safety and Precautions:
IV Therapy: Potassium must be diluted and infused slowly to prevent phlebitis and cardiac complications. Never give IV push potassium.
Fetal Monitoring: While the fetus is small at 8 weeks, maternal stability is paramount for fetal well-being. Severe dehydration and ketosis can be harmful.
Fall Risk: Patients may be weak and dizzy from dehydration and orthostatic hypotension. Implement fall precautions.
Nursing Procedure & Medication FlowProcedure: Initiating Care for HG
1. Assess: Vital signs, orthostatic BP, weight, mucous membranes, urine for ketones/SG.
2. Plan: Secure IV access (18-20 gauge). Prepare IV fluids with electrolytes as ordered.
3. Implement: Start IV infusion. Administer IV antiemetic (e.g., Ondansetron 4-8 mg IV) 30 minutes before attempting oral intake.
4. Evaluate: Monitor for decreased vomiting, increased urine output, improved lab values, and patient reporting feeling better.
Medication: IV Potassium Chloride (KCl)
- Action: Replaces potassium lost from vomiting.
- Precautions: Must be diluted. Maximum concentration for peripheral IV is usually 10 mEq/100 mL. Infusion rate typically should not exceed 10 mEq/hour unless in ICU with cardiac monitoring. Always use an IV pump.
- Monitoring: Monitor for burning at IV site. Assess serum potassium levels and monitor ECG for signs of hyperkalemia (peaked T waves) or persistent hypokalemia (U waves, flat T waves).
A Word from Your Senior Nurse
"In the whirlwind of morning sickness, it's our job to see when 'normal' nausea crosses the line into dangerous territory. That urine dipstick is your best friend—ketones and high specific gravity are the red flags that tell you this mom needs help, not just encouragement. Remember, you're correcting a metabolic crisis. Every bag of IV fluids you hang is stabilizing her circulation and protecting that tiny, developing life inside. In clinicals and on the NCLEX, think like a detective: gather the objective data, and let it guide your priorities. Your sharp assessment skills can prevent an ER admission from becoming an ICU stay."
Hyperemesis Gravidarum — Severe, persistent nausea and vomiting during pregnancy leading to weight loss (>5% of pre-pregnancy weight), dehydration, electrolyte imbalances, and ketosis.
Ketonuria — The presence of ketone bodies in the urine, indicating the body is breaking down fat for energy due to starvation or insufficient carbohydrate intake.
Urine Specific Gravity — A measure of the concentration of solutes in urine. Normal range is 1.005-1.030. A high value (>1.030) indicates concentrated urine and dehydration.
Fluid Volume Deficit — A state of decreased intravascular, interstitial, and/or intracellular fluid. In HG, it is caused by excessive vomiting and inadequate fluid intake.
Metabolic Acidosis (Starvation Ketosis) — A condition where the blood becomes too acidic due to the accumulation of ketoacids produced when the body breaks down fat for energy in the absence of sufficient glucose.