A nurse is assessing a client with gestational hypertension who is at 34 weeks of gestation.
The nurse notes that the client’s blood pressure is 160/100 mmHg, her urine protein is 3+, and she has mild edema in her lower extremities.
The nurse also observes that the client has brisk deep tendon reflexes and clonus.
How should the nurse interpret these findings?
The client has mild preeclampsia and needs close monitoring
The client has severe preeclampsia and needs immediate delivery.
The client has eclampsia and needs magnesium sulfate and anticonvulsants
The client has chronic hypertension and needs antihypertensive medication adjustment
The Correct Answer is B
The correct answer is choice B. The client has severe preeclampsia and needs immediate delivery. Severe preeclampsia is diagnosed when the blood pressure is at least 160/100 mmHg, the urine protein is 3+ or more, and there are signs of organ damage or central nervous system involvement, such as brisk deep tendon reflexes and clonus. These findings indicate a high risk of eclampsia, which is a life-threatening condition characterized by seizures. Immediate delivery is the only definitive treatment for preeclampsia and eclampsia.
Choice A is wrong because the client has more than mild preeclampsia. Mild preeclampsia is diagnosed when the blood pressure is at least 140/90 mmHg, the urine protein is 1+ or 2+, and there are no signs of organ damage or central nervous system involvement. Close monitoring may be appropriate for mild preeclampsia, depending on the gestational age and fetal status.
Choice C is wrong because the client does not have eclampsia yet. Eclampsia is diagnosed when the client has preeclampsia and seizures. Magnesium sulfate and anticonvulsants are used to prevent and treat seizures in eclampsia, but they do not cure preeclampsia. Delivery is still necessary to resolve the condition.
Choice D is wrong because the client does not have chronic hypertension. Chronic hypertension is high blood pressure that was present before pregnancy or that occurs before 20 weeks of gestation. The client’s blood pressure was normal before pregnancy and increased after 20 weeks of gestation, indicating gestational hypertension or preeclampsia.
Antihypertensive medication adjustment may be needed for chronic hypertension
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Drinking plenty of fluids if there is decreased fetal movement is wrong because it will not improve the condition of the baby or the placenta.Decreased fetal movement can be a sign of fetal distress due to placental abruption and needs immediate medical attention.
Choice A is correct because vaginal bleeding is a common symptom of placental abruption and indicates that the placenta has separated from the uterus.
Choice B is correct because monitoring blood pressure at home regularly is important for women with gestational hypertension, as high blood pressure is a risk factor for placental abruption.
Choice C is correct because lying down on the left side can improve blood flow to the uterus and the baby, and may help relieve abdominal pain caused by placental abruption.
Correct Answer is C
Explanation
The correct answer is choice C.Elevated serum transaminases indicate liver damage, which is one of the features of HELLP syndrome.HELLP syndrome is a rare pregnancy complication that is a type of preeclampsia and has similar symptoms.It stands for hemolysis, elevated liver enzymes, and low platelet count.
Choice A is wrong because elevated serum creatinine indicates kidney damage, which is not specific for HELLP syndrome.Kidney damage can occur in preeclampsia or eclampsia as well.
Choice B is wrong because elevated serum uric acid is also not specific for HELLP syndrome.It can be a marker of preeclampsia or eclampsia, but it is not part of the diagnostic criteria for HELLP syndrome.
Choice D is wrong because elevated serum glucose is not related to HELLP syndrome.It can be a sign of gestational diabetes, which is a different pregnancy complication.
Normal ranges for serum transaminases are 10 to 40 U/L for AST and 7 to 56 U/L for ALT.Normal ranges for serum creatinine are 0.5 to 1.1 mg/dL for women.Normal ranges for serum uric acid are 2.4 to 6.0 mg/dL for women.Normal ranges for serum glucose are 70 to 100 mg/dL for fasting and less than 140 mg/dL for postprandial.
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