Choice A rationale

The client’s symptoms of elevated blood pressure, 3+ edema in the lower extremities, and 3+ proteinuria are indicative of preeclampsia. Preeclampsia is a complication of pregnancy that begins after 20 weeks of gestation in women whose blood pressure had previously been in the standard range. It is associated with high blood pressure and signs of damage to another organ system, often the liver and kidneys. In this case, the nurse should initiate seizure precautions and monitor the client’s neurological status and liver function studies. Seizure precautions are necessary because eclampsia, a severe form of preeclampsia, can lead to seizures. Monitoring neurological status can help detect changes in the client’s condition, and liver function studies can help assess the impact of preeclampsia on the liver.

Choice B rationale

While the client does have a history of chronic hypertension, the current symptoms suggest a condition more severe than chronic hypertension. Administering antihypertensive medication and monitoring blood pressure and heart rate would be appropriate actions for managing chronic hypertension, but they may not be sufficient to address the client’s current condition.

Choice C rationale

Gestational diabetes is a condition characterized by high blood sugar levels that develop during pregnancy in women who did not have diabetes before pregnancy. The client’s symptoms do not indicate gestational diabetes. While administering insulin and monitoring blood glucose levels and fetal heart rate would be appropriate actions for managing gestational diabetes, they do not address the client’s current symptoms.

Choice D rationale

Preterm labor refers to regular contractions of the uterus resulting in changes in the cervix that start before 37 weeks of pregnancy. The client’s symptoms do not suggest preterm labor. Administering tocolytics and monitoring contraction pattern and cervical dilation would be appropriate actions for managing preterm labor, but they do not address the client’s current symptoms.

The correct answer is: d. Right lower

Choice A: Right upper

Reason: The right upper quadrant is not typically where fetal heart tones are auscultated when the fetal back is on the right side and the head is in the lower part of the uterus. This area is more likely to be associated with the breech presentation if the fetus’s head is in the fundus.

Choice B: Left upper

Reason: The left upper quadrant would be considered if the fetal back was on the left side and the head was in the fundus. Since the nurse palpated the fetal back on the right side, this option is not applicable.

Choice C: Left lower

Reason: The left lower quadrant would be relevant if the fetal back was on the left side and the head was in the lower part of the uterus. Given the fetal back is on the right side, this is not the correct location.

Choice D: Right lower

Reason: The correct answer is the right lower quadrant. When the nurse palpates a round, firm, movable part (likely the head) in the fundus and a long, smooth surface (the back) on the right side, it indicates that the fetus is in a cephalic (head-down) position with its back on the right. Therefore, the fetal heart tones are best auscultated in the right lower quadrant.