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?
1. Weigh the client.
2. Give 1 liter of lactated Ringer's solution IV.
3. Administer 30 ml Maalox (magnesium hydroxide) orally.
4. Encourage clear liquids orally.
2
Rationale 1: Weighing the client provides information on weight gain or loss, but is not the top priority in a patient with excessive vomiting during pregnancy. The vital signs indicate hypovolemia.
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.
Rationale 4: Lack of tolerance of oral fluids through excessive vomiting is what has led to the hypovolemia.
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