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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
The correct answer is choices B, C, D, and E.These are all risk factors for pre-eclampsia according to various sources.
Choice A is wrong because age over 35 years is not a risk factor for pre-eclampsia by itself, although it may be associated with other conditions that increase the risk, such as chronic hypertension or diabetes.
Pre-eclampsia is a complication of pregnancy that involves high blood pressure, protein in the urine, and organ damage.It can affect both the mother and the fetus and can lead to serious complications such as eclampsia (seizures), placental abruption, and stillbirth.It is more common in first pregnancies, especially with a new partner, because of the immune response to the foreign fetal antigens.Obesity, diabetes mellitus, and multiple gestation are also risk factors because they increase the metabolic and vascular demands on the placenta and the mother.
Normal ranges for blood pressure and proteinuria in pregnancy are:
• Blood pressure: less than 140/90 mmHg
• Proteinuria: less than 300 mg/24 hours or less than 30 mg/dL on a random urine sample
Correct Answer is C
Explanation
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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