A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is of greatest concern to the nurse?

Dipstick value of 3+ for protein in her urine

Pitting pedal edema at the end of the day

Weight gain of 0.5 kg during the past 2 weeks

Blood pressure (BP) increase to 138/86 mm Hg

Answer and Explanation

The Correct Answer is A

Choice A reason: Dipstick value of 3+ for protein in her urine is a sign of significant proteinuria, which is one of the diagnostic criteria for preeclampsia, along with hypertension. Proteinuria indicates renal damage and impaired glomerular filtration, which can lead to complications, such as oliguria, eclampsia, or HELLP syndrome.

Choice B reason: Pitting pedal edema at the end of the day is a common and expected finding in pregnancy, as it results from the increased blood volume, venous pressure, and fluid retention. Edema is not a reliable indicator of preeclampsia, unless it is severe, generalized, or sudden.

Choice C reason: Weight gain of 0.5 kg during the past 2 weeks is a normal and expected finding in pregnancy, as it reflects the growth and development of the fetus, placenta, and maternal tissues. Weight gain is not a reliable indicator of preeclampsia, unless it is excessive, rapid, or associated with edema.

Choice D reason: Blood pressure (BP) increase to 138/86 mm Hg is a mild elevation that may indicate gestational hypertension, but not preeclampsia, unless it is accompanied by proteinuria or other signs of organ dysfunction. The diagnostic threshold for preeclampsia is a BP of 140/90 mm Hg or higher on two occasions at least four hours apart.

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Correct Answer is C

Explanation

Choice A reason: Initiation of pushing is not an appropriate nursing action, as it can increase the bleeding and the risk of placental separation, which can cause fetal hypoxia, hemorrhage, or shock. Pushing is contraindicated in clients with placenta previa, which is a condition where the placenta covers the cervical opening and can cause painless, bright red bleeding in the third trimester.

Choice B reason: Examination to determine cervical status is not an appropriate nursing action, as it can cause trauma and perforation of the placenta, which can lead to severe bleeding and infection. Examination is contraindicated in clients with placenta previa, unless it is confirmed by ultrasound that the placenta is not low-lying or covering the cervix.

Choice C reason: Preparation for cesarean birth is an appropriate nursing action, as it is the preferred mode of delivery for clients with placenta previa, especially if the bleeding is heavy, the fetus is mature, or the fetal distress is present. Cesarean birth can prevent the complications of placenta previa, such as fetal hypoxia, hemorrhage, or shock.

Choice D reason: A magnesium sulfate infusion is not an appropriate nursing action, as it is a drug that prevents seizures and lowers the blood pressure in clients with severe preeclampsia, which is a hypertensive disorder of pregnancy. Magnesium sulfate is not indicated for clients with placenta previa, unless they also have severe preeclampsia or eclampsia.

A. Tampons are safe to use to absorb the leaking amniotic fluid. B. Report a temperature less than 37 degrees C. C. Do not engage in sexual activity. D. Taking frequent tub baths is safe.

Correct Answer is C

Explanation

Choice A reason: Tampons are not safe to use to absorb the leaking amniotic fluid, because they can introduce bacteria into the vagina and uterus, and increase the risk of infection and preterm labor. The nurse should instruct the client to use sanitary pads instead, and change them frequently.

Choice B reason: Reporting a temperature less than 37 degrees C is not a necessary activity, because it is a normal finding and does not indicate any complication. The nurse should instruct the client to report a temperature greater than 37.8 degrees C, which can be a sign of infection or chorioamnionitis.

Choice C reason: Not engaging in sexual activity is a recommended activity, because it can help prevent further rupture of membranes, infection, and preterm labor. The nurse should instruct the client to avoid any vaginal or cervical stimulation, such as intercourse, douching, or tampon use.

Choice D reason: Taking frequent tub baths is not a safe activity, because it can expose the vagina and uterus to contaminated water, and increase the risk of infection and preterm labor. The nurse should instruct the client to take showers instead, and avoid submerging the lower body in water.

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A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is of greatest concern to the nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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