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A nurse is caring for a client at 34 weeks gestation.

Medical History: The client has a history of gestational diabetes and mild hypertension.

Diagnostic Results: The latest ultrasound shows normal fetal growth and development. Blood sugar levels have been slightly elevated in the past week.

Vital Signs: Blood pressure has been steadily increasing over the past few hours. Heart rate and temperature remain within normal limits.

Complete the diagram by selecting the condition the client is most likely experiencing? Two actions the nurse should take to address that condition and two parameters the nurse should monitor to assess the client’s progress

Answer and Explanation

The Correct Answer is []

Condition

  • A. Preeclampsia is the most likely condition the client is experiencing given the following:
    • History of gestational diabetes and mild hypertension.
    • Recent elevation in blood pressure.
    • Preeclampsia is characterized by high blood pressure and can be associated with kidney involvement, as suggested by the increased blood pressure.

Actions

  1. Administer prescribed antihypertensive medication: This is crucial for managing preeclampsia, as it helps lower blood pressure and prevent complications.

  2. Monitor blood pressure and urine protein levels regularly: Essential for assessing the progression of preeclampsia and guiding treatment decisions. Monitoring helps track whether the condition is worsening or responding to treatment.

Parameters to Monitor

  1. Blood pressure readings: These are directly related to the severity of preeclampsia and help assess if the treatment is effective.

  2. Level of protein in urine: Elevated protein levels indicate kidney involvement, which is a common complication of preeclampsia.


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Related Questions

Correct Answer is C

Explanation

The estimated date of delivery (EDD) using Naegele's rule is _.

Step 1: Add 7 days to the first day of the last menstrual period. May 8 + 7 days = May 15

Step 2: Count 3 months back. May - 3 months = February

Step 3: Adjust the year if necessary. The year remains the same.

The estimated date of delivery is February 15 of the following year.

Correct Answer is ["A","C","D"]

Explanation

Rationale for Choice A: Visual disturbances
Preeclampsia: Visual disturbances, such as blurred vision or seeing spots, can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and protein in the urine. It typically develops after 20 weeks of gestation and can progress rapidly.
Potential complications: If left untreated, preeclampsia can lead to seizures (eclampsia), stroke, liver and kidney failure, premature birth, and even death of the mother or baby.
Prompt reporting: Early recognition and management of preeclampsia are crucial for preventing adverse outcomes. Therefore, visual disturbances should be reported to the provider immediately to initiate further assessment and potential interventions.

Rationale for Choice B: Fetal heart rate
No indication for reporting: While monitoring fetal heart rate is essential during pregnancy, the promptness of reporting it to the provider depends on specific concerns. In this case, the fetal heart tones are documented as 1, suggesting a normal rate and rhythm. There's no immediate indication for reporting it as a concerning finding.

Rationale for Choice C: Blood pressure
Hypertension: High blood pressure is a key feature of preeclampsia. Although blood pressure readings are not provided in the scenario, the nurse should measure and report them to the provider, as hypertension is a critical finding that could necessitate further evaluation and treatment.

Rationale for Choice D: Deep tendon reflexes
Hyperreflexia: The client's deep tendon reflexes are 3+, which is considered hyperreflexia. Hyperreflexia can be a neurological sign of preeclampsia, indicating increased excitability of the nervous system. It's important to report this finding to the provider for further assessment and monitoring.

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