A pregnant client at 14 weeks' gestation is diagnosed with hyperemesis gravidarum. The most recent vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first?
1. Weigh the client.
2. Encourage clear liquids orally.
3. Give 1 L of lactated Ringer solution IV.
4. Administer 30 mL Maalox (magnesium hydroxide) orally.
3
Explanation:
1. Weighing the client provides information on weight gain or loss, but it is not the top priority in a client with excessive vomiting during pregnancy. The vital signs indicate hypovolemia. The client needs IV fluids.
2. The client needs IV fluids because of the vital signs indicating hypovolemia. Oral fluids are not likely to be tolerated well by a client with hyperemesis. Lack of tolerance of oral fluids through excessive vomiting is what has led to the hypovolemia.
3. The vital signs indicate hypovolemia. Giving this client a liter of lactated Ringer solution intravenously will reestablish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down.
4. The vital signs indicate hypovolemia. There is no indication that the client has dyspepsia. The client needs IV fluids.
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