A nurse is admitting a client who is to undergo paracentesis for removal of ascitic fluid. Which of the following actions should the nurse take?

A. State Nurse Practice Act: The State Nurse Practice Act defines the legal scope of practice for nurses within that state, including permissible tasks, delegation guidelines, and licensure requirements. Consulting it ensures that the nurse acts within legal and professional boundaries.

B. Verbal direction from the nurse manager: While guidance from a manager can clarify expectations, it does not supersede legal regulations or define the nurse’s authorized scope of practice. Following only verbal instructions without legal backing may place the nurse at risk of practicing outside their scope.

C. Institutional policies and procedures: Policies provide guidance on how tasks should be performed safely within a facility, but they do not define the nurse’s legal scope of practice. These should be used in conjunction with state regulations, not as the primary authority.

D. Written prescription from the provider: A provider’s order indicates what care is needed for the client but does not grant a nurse legal authority to perform tasks outside their scope of practice. The nurse must ensure the action is permitted under state law before implementation.

Rationale for correct choices

• Intrauterine growth restriction: The client has experienced persistent nausea and vomiting, reduced oral intake, and a 1.8 kg (4 lb) weight loss over 5 weeks. These factors contribute to maternal malnutrition, which can limit fetal growth and development. Early identification of inadequate maternal nutrition is critical to prevent complications such as low birth weight, preterm birth, and impaired fetal organ development.

• Thiamine deficiency: Prolonged vomiting and poor nutritional intake increase the risk of vitamin deficiencies, particularly thiamine (vitamin B1). Thiamine deficiency in pregnancy can lead to Wernicke’s encephalopathy, neurological complications, and exacerbate maternal fatigue. Prompt recognition and supplementation are essential for both maternal and fetal health.

Rationale for incorrect choices

• Hypernatremia: While dehydration may accompany vomiting, severe vomiting usually leads to hyponatremia and hypokalemia (electrolyte loss) along with metabolic alkalosis. Hypernatremia is less likely than other complications in this scenario, as the client’s main concern is inadequate intake rather than excessive sodium loss.

• Amniotic fluid embolism: Amniotic fluid embolism is an acute, rare obstetric emergency that typically occurs during labor or immediately postpartum. The client’s current presentation in the first trimester does not indicate risk for this condition.

• Chorioamnionitis: Chorioamnionitis is an intrauterine infection usually associated with membrane rupture and labor. There is no report of infection, fever, or membrane compromise in this client. It is not an immediate risk at this stage of pregnancy.