A nurse on a step-down unit is admitting a client.

Exhibits

Drag words from the choices below to fill in each blank in the follow sentence.

The client is at risk for developing

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and

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.

Rationale for correct choices:

• Blood pressure: A reading of 148/94 mm Hg is elevated and meets criteria for gestational hypertension, especially in a client who is gravida 1 para 0. It raises concern for preeclampsia and must be closely monitored, particularly with concurrent symptoms like headache and edema.
• DTR: A deep tendon reflex of 3+ is considered hyperreflexic and may signal increased central nervous system irritability. In the setting of elevated blood pressure and other preeclampsia signs, it raises concern for worsening severity or impending seizure activity.
• Lower extremity assessment: The presence of 1+ dependent edema can be a normal pregnancy finding, but when paired with facial swelling, recent weight gain, and elevated blood pressure, it becomes significant and suggests fluid retention associated with preeclampsia.
• Weight assessment: A gain of 0.68 kg (1.5 lb) in a week may seem modest, but when it is sudden and combined with facial and dependent edema, it can indicate abnormal fluid accumulation. This pattern is concerning for preeclampsia and requires follow-up.
• Nausea: While nausea is common in pregnancy, its presence along with right upper quadrant pain and headache raises red flags for severe preeclampsia or HELLP syndrome. These are warning signs of potential hepatic involvement or worsening disease.

Rationale for incorrect choices:

• Fundal height: A fundal height of 29 cm is consistent with gestational age around 29 weeks and does not indicate an abnormal finding in this context. No follow-up is needed unless measurements are inconsistent with gestational dating.
• Respiratory assessment: The client’s lungs are clear to auscultation and respirations are even and non-labored. Oxygen saturation is 95% on room air, which is within normal range during pregnancy, so no respiratory issues require intervention.
• Fetal heart tracing: A fetal heart rate of 140/min is within the normal range of 110–160 beats per minute. There are no reported decelerations or signs of distress, so no immediate follow-up is indicated for the fetal tracing.

Rationale:

A. Instruct the client to be NPO for six hours prior to the procedure: Amniocentesis is typically done under local anesthesia and does not require sedation or general anesthesia, so there is no need for the client to be NPO beforehand.

B. Instruct the client to maintain a full bladder for the procedure: A full bladder is required during early pregnancy to help lift the uterus for better visualization. However, at 22 weeks gestation, the uterus is already an abdominal organ, and a full bladder is not necessary.

C. Monitor the fetal heart rate prior to the procedure: Monitoring the fetal heart rate before an amniocentesis is essential to establish a baseline and ensure fetal well-being. It also aids in identifying any immediate changes following the procedure.

D. Place the client in Trendelenburg position during the procedure: The Trendelenburg position is not appropriate for amniocentesis. The client is typically placed in a supine or slightly tilted position to allow proper access to the uterus and avoid vena cava compression.