The prenatal clinic nurse is caring for a patient with hyperemesis gravidarum at 14 weeks' gestation. The vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first?

Question

1. Weigh the patient.
2. Give 1 liter of lactated Ringer's solution IV.
3. Administer 30 ml Maalox (magnesium hydroxide) orally.
4. Encourage clear liquids orally.

Answer 1

Correct Answer: 2
Rationale 1: Weighing the patient provides information on weight gain or loss, but it is not the top priority in a patient with excessive vomiting during pregnancy. The vital signs indicate hypovolemia. The patient needs IV fluids.
Rationale 2: The vital signs indicate hypovolemia. Giving this patient a liter of lactated Ringer's solution intravenously will re-establish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down.
Rationale 3: The vital signs indicate hypovolemia. There is no indication that the patient has dyspepsia. The patient needs IV fluids.
Rationale 4: The patient needs IV fluids because of the vital signs indicating hypovolemia. Oral fluids are not likely to be tolerated well by a patient with hyperemesis. Lack of tolerance of oral fluids through excessive vomiting is what has led to the hypovolemia.