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A nurse is assisting with the care of a client who has preeclampsia.

Exhibits

Complete the following sentence by using the lists of options

The nurse should first address the client’s

followed by the client's
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

  • Blood pressure. The client’s blood pressure is severely elevated (162/110 mm Hg), indicating severe preeclampsia. Uncontrolled hypertension increases the risk of stroke, placental abruption, and eclampsia (seizures). Immediate interventions such as antihypertensive medications (e.g., labetalol or hydralazine) should be initiated to lower blood pressure and prevent complications.
  • Respiratory rate. The client’s respiratory rate is 20/min, which is within the normal range (12–20/min). There is no indication of respiratory distress or compromise, making this a lower priority.
  • Deep tendon reflexes. The client has 3+ deep tendon reflexes, which suggest neuromuscular irritability, a sign of worsening preeclampsia. However, while hyperreflexia is concerning, severe hypertension poses a more immediate risk of stroke or seizure, making it the first priority.
  • Platelet count. The client’s platelet count is critically low (95,000/mm³), which is a hallmark of HELLP syndrome (Hemolysis, Elevated Liver Enzymes, and Low Platelets). Low platelets increase the risk of bleeding complications, particularly in cases of delivery, epidural anesthesia, or cesarean section. Monitoring for further platelet decline and signs of HELLP progression (right upper quadrant pain, worsening liver function, or increased hemolysis) is essential.
  • Hematocrit. The client’s hematocrit is 35%, which is within the normal range for pregnancy (33–47%). Although anemia is present (Hgb 10 g/dL), it is not an immediate life-threatening concern, making it a lower priority than the platelet count.
  • Peripheral edema. The client has +2 pitting edema, which is common in preeclampsia, but it is not as critical as severe hypertension or thrombocytopenia. While worsening edema can indicate fluid retention and organ dysfunction, it does not require immediate intervention compared to other findings.


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Related Questions

Correct Answer is B

Explanation

A. FHR 160/min. A fetal heart rate (FHR) of 160 beats per minute is within the normal range of 110–160 bpm. While monitoring for variability and accelerations is important, this is not an immediate concern.
B. Fundal height 24 cm. Fundal height in centimeters should approximately match the gestational age in weeks (±2 cm). At 28 weeks, a fundal height of 24 cm is lower than expected, suggesting intrauterine growth restriction (IUGR), oligohydramnios, or inaccurate dating. This deviation requires further evaluation, making it the priority finding.
C. Blood pressure 136/84 mm Hg. Although slightly elevated from a typical baseline, this blood pressure reading does not meet the threshold for gestational hypertension (≥140/90 mm Hg). Monitoring for trends and preeclampsia symptoms is necessary, but this finding alone is not an urgent concern.
D. Trace protein on urine reagent strip (expected: none). A trace amount of protein in the urine can be a normal finding due to increased renal filtration during pregnancy. However, persistent proteinuria with hypertension could indicate preeclampsia. In this case, the amount is minimal and does not require immediate intervention.

Correct Answer is A

Explanation

A. Poor skin turgor. Hyperemesis gravidarum causes severe nausea and vomiting, leading to dehydration. Poor skin turgor is a common sign of dehydration, along with dry mucous membranes, decreased urine output, and tachycardia. Prompt fluid replacement is necessary to prevent complications.
B. Decreased pulse rate. Dehydration from excessive vomiting usually leads to tachycardia (increased heart rate), not bradycardia (decreased pulse rate). The body compensates for fluid loss by increasing heart rate to maintain adequate circulation and perfusion.
C. Increased fundal height. Hyperemesis gravidarum does not cause an increase in fundal height. Fundal height is typically affected by factors such as multiple gestation, polyhydramnios, or fetal growth abnormalities, but not excessive vomiting.
D. Proteinuria. Proteinuria is not a hallmark sign of hyperemesis gravidarum. It is more commonly associated with conditions like preeclampsia. However, ketonuria may be present due to prolonged vomiting and starvation, indicating fat breakdown for energy.

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