A nurse is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum.Which of the following are findings of this condition? (Select all that apply.)

The nurse should prioritize monitoring the client's fundal tone followed by the client's blood pressure. Here's why:

1. Fundal Tone: The client's fundus is boggy and not firming up with massage. This is a priority concern as it indicates uterine atony, which is a major cause of postpartum hemorrhage.
2. Blood Pressure: Monitoring blood pressure is crucial as the client is experiencing heavy lochia, and a decrease in blood pressure can indicate hypovolemic shock due to blood loss.

So, the completed sentence would be:

• The nurse should first monitor the client's fundal tone followed by the client's blood pressure.

Taking care of immediate risks and stabilizing the patient is key in such cases.

Choice A rationale

Informing the client to expect dark-colored stools is inaccurate for methotrexate administration. Dark stools typically indicate gastrointestinal bleeding, not a side effect of methotrexate.

Choice B rationale

Wearing two pairs of gloves is necessary when handling methotrexate as it is a cytotoxic drug. This protects healthcare workers from accidental exposure to the medication, which can be harmful.

Choice C rationale

Methotrexate is typically administered intramuscularly or orally, not subcutaneously. Administering it subcutaneously is incorrect and would not be effective for treating an ectopic pregnancy.

Choice D rationale

While it is essential to counsel the client on safe intercourse practices, instructing to use a condom for only 7 days post-administration is not specific or relevant to the methotrexate therapy for ectopic pregnancy.