Client's chart is reviewed.

Exhibits

Complete the diagram by dragging from the choice area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Rationale for Correct Choices

• Gestational hypertension: Gestational hypertension is defined as new-onset hypertension after 20 weeks of gestation without proteinuria or other systemic findings of preeclampsia. While her other symptoms like epigastric pain can be associated with preeclampsia, they are also common pregnancy complaints or could be attributed to other factors. Normal lab findings also rule out preeclampsia.
• Obtain baseline weight: Tracking weight helps assess fluid retention, which can indicate worsening disease. Accurate baseline measurements guide ongoing monitoring and treatment decisions.
• Begin HTN medication: Elevated blood pressure poses a risk for maternal complications such as stroke or organ damage. Initiating antihypertensive therapy is essential to manage blood pressure and prevent severe complications.
• Blood pressure: Continuous monitoring of blood pressure is critical to evaluate the effectiveness of interventions and detect rapid increases that could indicate progression to severe preeclampsia or eclampsia.
• Daily fetal movement counts: Reduced fetal movements may indicate fetal compromise. Monitoring daily fetal activity helps assess fetal well-being and guides decisions about possible early delivery.

Rationale for Incorrect Choices

• Congestive heart failure: The client’s presentation lacks signs of pulmonary edema, S3 heart sounds, or dyspnea on exertion, which are typical features of heart failure.
• Preeclampsia with severe features: While the client has some symptoms of preeclampsia ( swelling, epigastric pain), the lack of proteinuria on the urine dipstick and the preliminary lab results showing no abnormalities make this diagnosis less likely at this point.
• Chronic hypertension: Chronic hypertension is present before 20 weeks gestation or preexisting. This client’s blood pressure was normal earlier in pregnancy, making chronic hypertension unlikely.
• Pain management for headache: The client did not report headaches, visual disturbances, or neurological symptoms, so headache management is not an immediate priority.
• Educate client on HTN management: Education is important but is not the immediate action needed for acute elevated blood pressure or potential preeclampsia complications.
• Administer diuretic: Diuretics are generally contraindicated in gestational diabetes and preeclampsia because they can reduce placental perfusion and worsen fetal outcomes.
• Lung sounds: While always important to monitor, lung sounds are not a primary parameter for gestational hypertension unless the client begins to show signs of pulmonary edema or fluid overload, which she is not.
• Weight gain: While weight is useful for monitoring fluid retention, it is not an immediate indicator of worsening condition compared with blood pressure and fetal movement.
• Pedal edema: Edema is a supportive finding but not a primary parameter for ongoing monitoring of hypertension progression.