Assessment of a primigravida at 32 weeks' gestation shows a blood pressure of 160/110 mm Hg, 4+ proteinuria and edema of the face and extremities.
Which complication are these findings consistent with?
Preeclampsia with severe features.
Gestational hypertension.
Eclampsia.
Preeclampsia without severe features.
The Correct Answer is A
Choice A rationale
A blood pressure of 160/110 mm Hg meets the criteria for severe hypertension (≥ 160/≥ 110 mm Hg). The presence of 4+ proteinuria and facial/extremity edema, coupled with severe range hypertension, precisely defines preeclampsia with severe features, indicating significant maternal risk.
Choice B rationale
Gestational hypertension is characterized by a blood pressure ≥ 140/90 mm Hg on two occasions, without proteinuria. This client's blood pressure is in the severe range, and proteinuria is present, ruling out isolated gestational hypertension as the correct diagnosis.
Choice C rationale
Eclampsia is diagnosed when a patient with preeclampsia develops new-onset generalized tonic-clonic seizures or unexplained coma. While the patient's findings indicate severe preeclampsia, the absence of seizure activity or coma means the condition has not progressed to eclampsia yet.
Choice D rationale
Preeclampsia without severe features is defined by blood pressure ≥ 140/90 mm Hg but < 160/110 mm Hg and proteinuria ≥ 0.3 g in a 24-hour urine specimen. This client's blood pressure of 160/110 mm Hg places her directly in the severe features category.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While exploring other client problems is a component of holistic care, it is not the most immediate and direct priority after a major decision like continuing pregnancy. The primary focus should shift to practical support and preparation for the forthcoming maternal role and necessary resources, ensuring safety and continuity of care.
Choice B rationale
Giving explicit approval is non-therapeutic and can interfere with the client's autonomy and decision-making process. The nurse's role is to provide nonjudgmental, supportive care and information, respecting the client's choice without imposing personal values or moral judgments on the situation.
Choice C rationale
Making an appointment is a practical step, but providing information about resources empowers the adolescent to navigate the complex healthcare system and social support networks independently, which is a broader and more enabling intervention for long-term self-care and success.
Choice D rationale
Providing information about resources and assistance, such as WIC, Medicaid, and parenting classes, directly addresses the practical and socio-economic challenges inherent in an adolescent pregnancy. This is essential for promoting positive maternal-fetal outcomes and self-efficacy in the client's chosen path.
Correct Answer is C
Explanation
Choice A rationale
The "taking in" phase immediately follows birth and typically lasts 1-2 days. During this period, the mother is largely passive and dependent, focusing on her own needs for rest and nourishment, and reliving the birth experience. She is often content to let others provide care for the infant while she rests and recovers.
Choice B rationale
The "letting go" phase is the final phase, occurring once the mother has settled at home, and involves the mother moving forward as a family unit. This phase involves relinquishing the previous childless lifestyle and adapting to her new role, including accepting the infant's increasing independence and addressing relationship changes with her partner.
Choice C rationale
The "taking hold" phase usually begins on the second or third day and lasts for several weeks. The mother becomes more independent and actively focused on the newborn's needs, exhibiting a strong interest in learning and taking charge of infant care. Asking multiple questions about care is a hallmark of this phase.
Choice D rationale
Early parenting is a broader, less specific term than the Reva Rubin's three-stage framework. While the behavior is certainly a part of early parenting, the phases ("taking in," "taking hold," and "letting go") specifically describe the mother's psychological adjustment to her new role and are the correct terminology for this specific behavioral stage.
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