A nurse is assisting in the care of a client at 24 weeks of gestation who has a blood pressure reading of 150/98 mm Hg. Which of the following actions should the nurse prioritize?
Assess the blood pressure after four hours.
Obtain a urine sample for proteinuria.
Ask the client about their daily dietary habits.
Weigh the client.
The Correct Answer is B
Choice A rationale
Monitoring blood pressure at 4 hour intervals is a standard nursing protocol for observing trends in gestational hypertension, which is defined as a systolic pressure ≥ 140 mm Hg or diastolic ≥ 90 mm Hg after 20 weeks. however, delayed assessment prevents the immediate identification of preeclampsia. Scientific management requires prompt data collection to determine if multi organ involvement is occurring, as waiting 4 hours could allow the condition to worsen without medical intervention or stabilization.
Choice B rationale
Proteinuria is a hallmark diagnostic sign of preeclampsia, reflecting glomerular capillary endotheliosis and increased permeability of the basement membrane in the kidneys. Normal urine protein is typically < 30 mg/dL on a dipstick or < 300 mg in a 24 hour collection. Identifying protein in the urine of a client with a blood pressure of 150/98 mm Hg is the priority to distinguish simple gestational hypertension from potentially life threatening preeclampsia at 24 weeks.
Choice C rationale
Assessing dietary habits, particularly sodium and protein intake, provides context for long term nutritional status and fluid retention. While high sodium might contribute to edema, it is not the primary cause of hypertension in pregnancy, which is rooted in vasospasm and endothelial dysfunction. This action is supportive and educational rather than diagnostic or urgent in the acute setting where a high blood pressure reading has already been documented and requires immediate pathological screening.
Choice D rationale
Measuring weight is necessary to detect rapid gains, often exceeding 2 kg or 4.4 lb per week, which suggests significant fluid shifts and generalized edema. Edema results from decreased plasma oncotic pressure and capillary leaking associated with systemic vascular damage. While weighing the client provides data on fluid status, it is less specific than a urine protein test for diagnosing preeclampsia and determining the severity of the hypertensive disorder in the current clinical moment.
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Correct Answer is D
Explanation
Choice A rationale
An age of 24 is considered a low-risk age group for the development of preeclampsia. The highest risk based on age occurs in pregnant individuals who are younger than 20 or older than 35. Nulliparous women in their early twenties generally have a baseline risk unless other medical factors are present. Preeclampsia involves systemic vascular endothelial dysfunction, and while it can occur at any age, 24 is not a statistically significant demographic risk factor in clinical practice.
Choice B rationale
Being Gravida 3 Para 2 means the client has had two previous births. Multigravida status, especially with the same partner and no history of hypertensive disorders in prior pregnancies, actually serves as a protective factor against preeclampsia. The risk is significantly higher for primigravida clients (first-time mothers) or those with a new biological partner, as the maternal immune system's adaptation to paternal antigens is thought to play a role in the normal development of the placenta.
Choice C rationale
A Body Mass Index (BMI) of 28 is categorized as overweight (normal range 18.5 to 24.9), but it is not considered the high-risk threshold for preeclampsia. A BMI of 30 or greater (obese) is the standard clinical benchmark that significantly increases the risk of hypertensive disorders of pregnancy. While being overweight increases metabolic stress, it does not carry the same degree of inflammatory and vascular risk as clinical obesity does for the development of preeclampsia.
Choice D rationale
Gestational hypertension is a major risk factor for the development of preeclampsia. Gestational hypertension is defined as a blood pressure ≥ 140/90 mmHg after 20 weeks of gestation in a previously normotensive client, without proteinuria. Approximately 15 percent to 50 percent of clients diagnosed with gestational hypertension will eventually develop proteinuria or end-organ dysfunction, meeting the diagnostic criteria for preeclampsia. Close monitoring of blood pressure, urine protein, and liver enzymes is essential for these high-risk clients.
Correct Answer is D
Explanation
Choice A rationale
While the implantation site, such as the fallopian tube, is the definition of an ectopic pregnancy, the site itself is the condition rather than a complication. Most ectopic pregnancies occur in the ampulla of the fallopian tube. While the location dictates how much space the embryo has to grow before causing pain or pressure, the location alone does not constitute an immediate life-threatening complication until it leads to the destruction of the surrounding tissue or major vascular structures.
Choice B rationale
A previous ectopic pregnancy is a significant risk factor for having another one in the future, but it does not directly increase the risk for acute complications during the current pregnancy event. It indicates that there may be underlying tubal damage or scarring that interferes with normal ovum transport. However, when assessing the immediate danger to a client currently experiencing an ectopic pregnancy, a past history is less critical than the current physiological status of the pregnancy.
Choice C rationale
A hysterotomy scar, often from a previous cesarean section, can be a site for a rare type of ectopic pregnancy known as a cesarean scar pregnancy. While this specific location carries high risks for uterine rupture and hemorrhage, it is a specific subtype of the condition. For a general diagnosis of ectopic pregnancy, the presence of a scar is a predisposing factor for where the pregnancy might implant, but it is not the primary source of acute medical complications.
Choice D rationale
A ruptured ectopic pregnancy is the most severe and life-threatening complication of this condition. When the fallopian tube or other implantation site can no longer contain the growing gestational sac, it tears, leading to massive internal hemorrhage into the peritoneal cavity. This results in hypovolemic shock, severe abdominal pain, and potential maternal death if not surgically addressed immediately. Rupture is the primary event that transforms an ectopic pregnancy from a stable medical situation into a surgical emergency.
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