# 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?

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> subject: Maternal Newborn Health

## 문제

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?

## 보기

1. Blood pressure of 110/70 mmHg
2. Weight loss of 2 pounds since last visit
3. Mild dehydration with dry mucous membranes
4. Ketonuria with specific gravity of 1.035 **✔ 정답**

**정답: 4**

## 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.

## 심화 해설

Clinical Reasoning & Priority Setting

When assessing a client with hyperemesis gravidarum (HG), the nurse must differentiate between expected clinical manifestations of the condition and findings that signal a risk for severe, potentially irreversible complications. The priority concern is the assessment finding that indicates a metabolic derangement requiring immediate intervention to prevent neurological injury.

Analysis of Assessment Findings

Ketonuria with an elevated urine specific gravity of 1.035 is the priority concern. This combination reflects a state of prolonged starvation and severe volume depletion. In the context of HG, persistent vomiting prevents adequate carbohydrate intake, forcing the body to catabolize fat stores for energy and producing ketone bodies. The high specific gravity indicates concentrated urine due to significant fluid deficit. This metabolic environment is a direct precursor to thiamine (vitamin B1) deficiency, a critical complication. Thiamine is an essential cofactor in carbohydrate metabolism, and its depletion can lead to Wernicke's encephalopathy, a rare but devastating neurological disorder characterized by the classic triad of confusion, ataxia, and nystagmus [1]. The presence of ketonuria confirms that the patient is in a catabolic state where thiamine stores are rapidly consumed, making neurological injury imminent without prompt intravenous thiamine replacement [1].

The other findings, while clinically relevant, represent expected or less urgent consequences of HG. A blood pressure of 110/70 mmHg is a normotensive reading and does not indicate hemodynamic instability. Weight loss of 2 pounds since the last visit is an anticipated finding in HG and, while requiring monitoring, does not represent an acute threat. Mild dehydration with dry mucous membranes is a common clinical sign of the condition; however, the objective data of ketonuria with a high specific gravity provides a more precise and alarming measure of the severity of the metabolic and nutritional deficit, which is the underlying mechanism for severe complications like Wernicke's encephalopathy and hypoxic-ischemic brain injury . The development of a core outcome measurement set for HG research highlights the importance of standardizing the measurement of such metabolic and nutritional outcomes to improve clinical assessment and intervention . Effective treatment strategies, as identified in systematic reviews, must address this profound nutritional disruption to prevent progression to severe maternal morbidity .References (research sources)

- [1]Wernicke encephalopathy in pregnancy associated with hyperemesis gravidarum: a case report.Case reportSzablewska AW, Czerwińska-Osipiak A, Krawczyk A, Piekarski R. (2025) · DOI: 10.1186/s12884-025-07830-7

## 임상 시나리오

Clinical Priority in Hyperemesis Gravidarum

The presence of **ketonuria** in a client with hyperemesis gravidarum (HG) represents a state of prolonged starvation and severe volume depletion. Persistent vomiting prevents adequate carbohydrate intake, forcing the body to catabolize fat stores and produce ketone bodies. This metabolic environment is a direct precursor to **thiamine (vitamin B1) deficiency**.

Priority Rationale

Ketonuria confirms the patient is in a catabolic state where thiamine stores are rapidly consumed. Without prompt intervention, this can lead to **Wernicke's encephalopathy**, a devastating neurological disorder characterized by the classic triad of confusion, ataxia, and nystagmus.

Nursing Actions

- Notify the provider immediately of the presence of ketonuria and elevated specific gravity.

- Anticipate orders for intravenous (IV) thiamine replacement *before* administering dextrose-containing fluids to prevent precipitating Wernicke's encephalopathy.

- Initiate IV fluid resuscitation with isotonic solutions as prescribed to correct volume depletion.

- Monitor strict intake and output, daily weights, and urine ketones.

Clinical Pearl

Always administer thiamine **prior to** glucose infusion in severely malnourished or starved patients to avoid acute thiamine depletion and neurological injury.

## 핵심 개념

- **Hyperemesis Gravidarum** — A severe form of nausea and vomiting in pregnancy characterized by persistent vomiting, weight loss, dehydration, and electrolyte imbalances.
- **Ketonuria** — The presence of ketone bodies in the urine, indicating that the body is breaking down fat for energy due to inadequate carbohydrate intake or starvation.
- **Wernicke Encephalopathy** — A serious neurological condition caused by thiamine (vitamin B1) deficiency, classically presenting with confusion, ataxia, and nystagmus.
- **Urine Specific Gravity** — A measure of urine concentration; an elevated value (e.g., 1.035) indicates concentrated urine typically due to dehydration or volume depletion.

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