A nurse is assessing a client who is 24 weeks pregnant and has preeclampsia.
Which of the following findings should the nurse report to the provider as a manifestation of severe preeclampsia?
Blood pressure of 150/90 mm Hg
Urine protein of 2+
Epigastric pain
Facial edema
The Correct Answer is C
This is a manifestation of severe preeclampsia that indicates liver involvement and can precede a seizure.
The nurse should report this finding to the provider immediately and prepare for possible delivery of the baby.
Choice A is wrong because blood pressure of 150/90 mm Hg is a sign of mild preeclampsia, not severe. Severe preeclampsia is diagnosed when the systolic pressure is 160 mm Hg or higher or the diastolic pressure is 110 mm Hg or higher.
Choice B is wrong because urine protein of 2+ is also a sign of mild preeclampsia, not severe. Severe preeclampsia is diagnosed when the urine protein is 3+ or higher.
Choice D is wrong because facial edema is a common finding in normal pregnancy and does not indicate severe preeclampsia. Other signs of severe preeclampsia include headache, blurred vision, oliguria, thrombocytopenia, and pulmonary edema.
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Related Questions
Correct Answer is A
Explanation
Headache that does not respond to analgesics.This is a possible sign of postpartum pre-eclampsia, a rare condition that occurs when a woman has high blood pressure and excess protein in her urine soon after childbirth.Postpartum pre-eclampsia can cause seizures and other serious complications if not treated.
Choice B is wrong because breast engorgement and tenderness are normal symptoms of breastfeeding and do not indicate postpartum pre-eclampsia.
Choice C is wrong because lochia rubra with small clots is a normal discharge of blood and tissue from the uterus after delivery and does not indicate postpartum pre-eclampsia.
Choice D is wrong because perineal pain and swelling are common after vaginal delivery and do not indicate postpartum pre-eclampsia.
Normal ranges for blood pressure are below 120/80 mm Hg and for protein in urine are below 150 mg/day.
Correct Answer is D
Explanation
The client should have a follow-up visit with the provider in a week.This is because preeclampsia can persist or develop after delivery and requires close monitoring of blood pressure and signs of organ injury.
Choice A is wrong because vaginal bleeding is normal after delivery and does not indicate a complication of preeclampsia.
Choice B is wrong because the client should not stop taking blood pressure medication without consulting the provider.Preeclampsia can cause hypertension that may need treatment even after delivery.
Choice C is wrong because breastfeeding is not contraindicated for women with preeclampsia.Breastfeeding may even lower blood pressure and help the uterus contract.
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