The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)?
Blood pressure reading is at the prenatal baseline.
Dependent edema has resolved.
Urinary output has increased.
The client complains of a headache and blurred vision.
The Correct Answer is D
A. Blood pressure reading is at the prenatal baseline. If blood pressure remains stable, it does not indicate worsening preeclampsia.
B. Dependent edema has resolved. A decrease in edema suggests an improvement, not worsening, of preeclampsia.
C. Urinary output has increased. Decreased urinary output is concerning in preeclampsia, while increased output suggests better kidney function.
D. The client complains of a headache and blurred vision. These are signs of severe preeclampsia, indicating possible cerebral edema or hypertensive crisis, which requires immediate medical attention.
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Correct Answer is D
Explanation
A. Increase the rate of maintenance IV infusion. Increasing IV fluids may help improve placental perfusion, but it is not the first action. Repositioning the client takes priority to improve blood flow before considering IV adjustments.
B. Administer oxygen using a nonrebreather mask. Oxygen is beneficial in improving fetal oxygenation, but positioning the client laterally should be done first to optimize blood flow before oxygen administration.
C. Elevate the client’s legs. Elevating the legs may be helpful in cases of hypotension, but this scenario describes late decelerations, which are related to uteroplacental insufficiency.
D. Place the client in the lateral position. Late decelerations are caused by uteroplacental insufficiency, leading to fetal hypoxia. The first action is to reposition the client to the lateral position, which improves blood flow to the placenta and enhances fetal oxygenation.
Correct Answer is D
Explanation
A. Number of previous pregnancies: While previous pregnancies can influence labor speed (multiparous clients often progress faster), it is not the most critical factor in assessing labor progression.
B. Maternal age: Advanced maternal age may increase labor complications, but it does not directly determine labor progression.
C. Gestational weight gain: Excessive weight gain can impact fetal size, but it is not the primary factor affecting labor progression.
D. Fetal size: Fetal size plays a significant role in labor progression. A large fetus may cause cephalopelvic disproportion (CPD), leading to slow or arrested labor, whereas a smaller fetus may allow for quicker labor progression.
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