A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia.
Which of the following findings should the nurse identify as inconsistent with preeclampsia?

Rationale for Correct Condition

Preeclampsia is characterized by hypertension (≥140/90 mm Hg) and proteinuria (≥300 mg/24 hr) or signs of systemic involvement such as headache and edema. The client’s elevated BP, significant proteinuria, headache, hyperreflexia, and pitting edema strongly indicate preeclampsia. The absence of seizures rules out eclampsia, and the gestational age excludes chronic hypertension with superimposed preeclampsia.

Rationale for Correct Actions

Magnesium sulfate prevents seizures by stabilizing neuronal excitability and reducing cerebral vasospasm. It also lowers BP by promoting vascular relaxation. External fetal monitoring detects fetal distress from utero-placental insufficiency caused by preeclampsia-related hypertension and endothelial dysfunction.

Rationale for Correct Parameters

Blood pressure reflects disease progression and response to antihypertensives. Severe hypertension increases the risk of cerebral hemorrhage and placental abruption. Deep tendon reflexes indicate neurological impairment. Hyperreflexia signals worsening preeclampsia, while absent reflexes may indicate magnesium toxicity.

Rationale for Incorrect Conditions

Gestational hypertension lacks proteinuria and systemic symptoms. Chronic hypertension with superimposed preeclampsia requires a pre-existing hypertensive diagnosis. Eclampsia involves seizures, which the client has not reported.

Rationale for Incorrect Actions

Ampicillin is not indicated without infection. Rh immune globulin is unnecessary without Rh incompatibility. Anticoagulants are not first-line for preeclampsia.

Rationale for Incorrect Parameters

Temperature is not directly related to preeclampsia. Petechiae are signs of coagulopathy, not primary indicators. Pruritus is irrelevant unless liver dysfunction is suspected.

Take-Home Points

• Preeclampsia involves multisystem dysfunction with endothelial damage.
• Magnesium sulfate prevents seizures but must be monitored for toxicity.
• Differentiation from gestational hypertension is crucial for management.
• Fetal monitoring is key to detecting early signs of compromise.

Choice A rationale

Proteinuria, the presence of protein in the urine, is not a typical immediate complication following an amniocentesis. It is more commonly associated with preeclampsia, a condition of pregnancy. While the nurse would monitor the patient's overall condition, proteinuria is not a direct risk related to the amniocentesis procedure itself.

Choice B rationale

Hemorrhage is a potential complication following an amniocentesis. The procedure involves inserting a needle through the abdominal wall and uterus to withdraw amniotic fluid, which carries a risk of bleeding at the insertion site, within the uterus, or even fetomaternal hemorrhage (bleeding from the fetal circulation into the maternal circulation). The nurse must monitor for signs of bleeding, such as increased pain, decreased blood pressure, or vaginal bleeding.

Choice C rationale

Hypoxia, a deficiency in the amount of oxygen reaching the tissues, is not a direct immediate complication of amniocentesis for the mother. While fetal well-being is monitored during and after the procedure, maternal hypoxia is not a typical risk associated with the amniocentesis itself.

Choice D rationale

Infection is a significant potential complication following an amniocentesis. The invasive nature of the procedure creates a risk of introducing bacteria into the amniotic cavity or the maternal tissues. The nurse should observe for signs of infection such as fever, chills, abdominal tenderness, or leakage of fluid from the insertion site.