A nurse is monitoring a client with gestational hypertension for signs of fluid retention and edema.
Which of the following assessments would be most helpful?
Measuring abdominal girth daily
Checking for pitting edema in the lower extremities
Weighing the client daily at the same time
Auscultating lung sounds for crackles
The Correct Answer is C
The correct answer is choice C. Weighing the client daily at the same time. This is because weight gain and edema are common signs of fluid retention and preeclampsia, a serious complication of gestational hypertension. Weighing the client daily at the same time can help monitor the fluid status and detect any sudden changes that may indicate worsening preeclampsia.
Choice A is wrong because measuring abdominal girth daily is not a reliable indicator of fluid retention or edema, as it can also be affected by fetal growth, uterine size, and maternal fat distribution.
Choice B is wrong because checking for pitting edema in the lower extremities is not a specific sign of preeclampsia, as it can also occur in normal pregnancies due to increased blood volume and venous pressure.
Choice D is wrong because auscultating lung sounds for crackles is not a helpful assessment for fluid retention and edema, as it is a late sign of pulmonary edema, which is a rare but life-threatening complication of severe preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Weighing the client daily at the same time.This is because weight gain and edema are common signs of fluid retention and preeclampsia, a serious complication of gestational hypertension.Weighing the client daily at the same time can help monitor the fluid status and detect any sudden changes that may indicate worsening preeclampsia.
Choice A is wrong because measuring abdominal girth daily is not a reliable indicator of fluid retention or edema, as it can also be affected by fetal growth, uterine size, and maternal fat distribution.
Choice B is wrong because checking for pitting edema in the lower extremities is not a specific sign of preeclampsia, as it can also occur in normal pregnancies due to increased blood volume and venous pressure.
Choice D is wrong because auscultating lung sounds for crackles is not a helpful assessment for fluid retention and edema, as it is a late sign of pulmonary edema, which is a rare but life-threatening complication of severe preeclampsia.
Correct Answer is A
Explanation
The correct answer is choice A. Headache and blurred vision.These are signs ofcerebral edemaor swelling of the brain, which can lead toeclampsia, a life-threatening complication of preeclampsia that causes seizures.
Choice B is wrong because nausea and vomiting are common symptoms of pregnancy and do not indicate a risk for eclampsia.
Choice C is wrong because edema and weight gain are also common in pregnancy and may be due to fluid retention or increased blood volume.
They are not specific signs of preeclampsia or eclampsia.
Choice D is wrong because proteinuria and oliguria are signs ofkidney damagedue to preeclampsia, but they do not directly increase the risk of eclampsia.However, they may indicate severe preeclampsia that requires close monitoring and treatment.
Normal ranges for blood pressure, proteinuria, platelet count, and liver enzymes are as follows:
• Blood pressure: less than 140/90 mm Hg
• Proteinuria: less than 300 mg per 24 hours
• Platelet count: 150,000 to 400,000 per microliter
• Liver enzymes: AST less than 40 U/L, ALT less than 45 U/L
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