A 32-week multigravida client with a history of preeclampsia arrives to the clinic for her routine appointment.
The nurse observes the client has an elevated blood pressure of 155/90 mm Hg. Which action should the nurse take?
Obtain a finger stick blood glucose.
Observe the strength and time of contractions.
Collect a urine specimen to screen for protein.
Inquire about a history of migraines.
The Correct Answer is C
Choice A rationale
A finger stick blood glucose is not a standard screening tool for preeclampsia. While clients with gestational diabetes can have an increased risk, an elevated blood pressure is the key indicator in this clinical scenario. The primary pathophysiology of preeclampsia does not involve glucose metabolism, making this a low-yield and inappropriate initial action.
Choice B rationale
Observing for the strength and time of contractions is relevant for assessing labor progression, but it is not the most appropriate initial action for an elevated blood pressure in a client with a history of preeclampsia. The priority is to investigate the cause of the hypertension and screen for the hallmark signs of the condition, such as proteinuria.
Choice C rationale
An elevated blood pressure of 155/90 mm Hg in a client with a history of preeclampsia is a critical finding. The next step is to collect a urine specimen to test for proteinuria, which, along with the hypertension, is a diagnostic criterion for preeclampsia. This is a crucial and immediate action to assess the client's current clinical status and guide further management.
Choice D rationale
While severe headaches can be a symptom of preeclampsia, inquiring about a history of migraines is not the most appropriate first step. The priority is to objectively assess the client for the definitive signs of preeclampsia, which include hypertension and proteinuria. While subjective symptoms are important, a urine specimen provides objective, diagnostic data.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A finger stick blood glucose is not a standard screening tool for preeclampsia. While clients with gestational diabetes can have an increased risk, an elevated blood pressure is the key indicator in this clinical scenario. The primary pathophysiology of preeclampsia does not involve glucose metabolism, making this a low-yield and inappropriate initial action.
Choice B rationale
Observing for the strength and time of contractions is relevant for assessing labor progression, but it is not the most appropriate initial action for an elevated blood pressure in a client with a history of preeclampsia. The priority is to investigate the cause of the hypertension and screen for the hallmark signs of the condition, such as proteinuria.
Choice C rationale
An elevated blood pressure of 155/90 mm Hg in a client with a history of preeclampsia is a critical finding. The next step is to collect a urine specimen to test for proteinuria, which, along with the hypertension, is a diagnostic criterion for preeclampsia. This is a crucial and immediate action to assess the client's current clinical status and guide further management.
Choice D rationale
While severe headaches can be a symptom of preeclampsia, inquiring about a history of migraines is not the most appropriate first step. The priority is to objectively assess the client for the definitive signs of preeclampsia, which include hypertension and proteinuria. While subjective symptoms are important, a urine specimen provides objective, diagnostic data.
Correct Answer is ["A","B","C"]
Explanation
- Estimated blood loss of 750 mL at delivery
- Although below the 1,000 mL threshold for major PPH, this amount is still significant for a vaginal delivery and may contribute to anemia and ongoing bleeding symptoms.
- Labor lasted 50 hours with vacuum-assisted delivery
- Prolonged labor and instrumental delivery are known risk factors for uterine atony and trauma, both of which can lead to PPH2.
- Second-degree perineal laceration and left lateral sulcus laceration
- These injuries can contribute to bleeding, especially if not adequately repaired or if bleeding persists from the site.
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