A nurse is caring for a 35-year-old female client who is at 37 weeks of gestation in the antepartum unit.
Complete the following sentence using the drop-down options: The nurse’s greatest concern is the client’s risk of developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"A"}
The nurse’s greatest concern is the client’s risk of developing preeclampsia with severe features related to elevated blood pressure and proteinuria.
Rationale for correct answers
Preeclampsia with severe features is diagnosed when a pregnant client has blood pressure ≥160/110 mm Hg, as seen in this case (162/112 mm Hg), along with signs of end-organ damage, such as proteinuria, thrombocytopenia, and elevated liver enzymes. The client has proteinuria, as detected in urinalysis, and laboratory markers of potential organ dysfunction, including elevated AST, ALT, LDH, and creatinine, all supporting progression to severe disease.
Elevated blood pressure is a hallmark of preeclampsia and places the client at risk for stroke, placental abruption, and fetal complications. Proteinuria (urinary excretion of excess protein due to endothelial dysfunction) confirms a worsening condition. Immediate interventions, including magnesium sulfate for seizure prevention and antihypertensives, are warranted.
Rationale for incorrect Response 1 options
- Gestational hypertension: Unlike gestational hypertension, which is hypertension without proteinuria or organ dysfunction, this client meets criteria for severe preeclampsia, making gestational hypertension an incomplete diagnosis.
- Placental abruption: No vaginal bleeding or symptoms like sudden abdominal pain suggestive of placental separation.
- Chorioamnionitis: No fever or foul-smelling amniotic fluid, ruling out intrauterine infection.
Rationale for incorrect Response 2 options
- Fetal distress: While late decelerations indicate uteroplacental insufficiency, the primary concern remains maternal preeclampsia, which secondarily leads to fetal distress.
- Oliguria: Though urine output is reduced, it is not the leading diagnostic criterion over hypertension and proteinuria.
- Contractions: Preterm labor is occurring, but contractions are not the main threat compared to severe preeclampsia risks.
Rationale for incorrect Response 3 options
- Vaginal bleeding: No signs of bleeding, ruling out placental abruption or other hemorrhagic complications.
- Fever: No elevated temperature indicative of infection.
- Hypoxia: Oxygen saturation is normal (98%), and the primary issue relates to vascular dysfunction rather than respiratory compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Headache in a postpartum patient, especially if severe, persistent, or accompanied by visual disturbances or hypertension, can be a sign of serious conditions such as preeclampsia or postpartum eclampsia. These conditions require immediate medical attention due to the potential for significant maternal morbidity and mortality.
Choice B rationale
Gestational age is a historical data point related to the pregnancy and delivery. While important for understanding the newborn's potential risks and maturity, it is not a priority concern in the immediate postpartum period for the mother unless complications related to preterm or post-term delivery arise in the mother.
Choice C rationale
Heartburn, or pyrosis, is a common discomfort during pregnancy due to hormonal changes and pressure on the stomach. While it can persist postpartum, it is generally not a priority concern unless it is severe, atypical, or associated with other concerning symptoms like chest pain, which could indicate a different underlying issue.
Choice D rationale
Abnormal liver function tests in the postpartum period can indicate serious conditions such as HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count), a severe form of preeclampsia that can occur postpartum. These abnormalities require prompt investigation and management due to the potential for life-threatening complications. .
Correct Answer is A
Explanation
Choice A rationale
Persistent feelings of sadness that are pervasive and interfere with daily functioning, coupled with severe fatigue that goes beyond typical postpartum tiredness and a marked loss of interest in activities, including bonding and caring for the newborn, are key indicators of postpartum depression. These symptoms are more intense and prolonged than the emotional lability often seen in the postpartum period.
Choice B rationale
Feeling anxious about the baby's well-being is a common experience for many postpartum individuals as they adjust to parenthood. As long as this anxiety does not impair their ability to care for the baby effectively, it is more likely a component of normal postpartum adjustment rather than indicative of postpartum depression.
Choice C rationale
Experiencing occasional mood swings and irritability is typical during the postpartum period due to hormonal shifts, sleep deprivation, and the significant life changes associated with a new baby. These fluctuations are usually transient and less severe than the persistent sadness and loss of interest seen in postpartum depression.
Choice D rationale
Feeling overwhelmed and having difficulty sleeping are common challenges for new parents due to the demands of newborn care. While these symptoms can contribute to or exacerbate postpartum depression, they are not solely indicative of it unless accompanied by persistent sadness, severe fatigue, and a loss of interest in activities.
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