A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?
Elevated blood pressure
Increased urine output
Joint pain
Vaginal discharge
The Correct Answer is A
Choice A reason: Elevated blood pressure is a hallmark sign of preeclampsia, which is a hypertensive disorder of pregnancy that can cause serious complications, such as eclampsia, HELLP syndrome, or placental abruption. The nurse should monitor the client's blood pressure regularly and report any readings above 140/90 mm Hg to the provider.
Choice B reason: Increased urine output is not a sign of preeclampsia, but rather a normal physiological change of pregnancy, as the renal blood flow and glomerular filtration rate increase. A client with preeclampsia may have decreased urine output, which can indicate renal impairment or oligohydramnios.
Choice C reason: Joint pain is not a sign of preeclampsia, but rather a common discomfort of pregnancy, as the hormones relaxin and progesterone loosen the ligaments and joints. A client with preeclampsia may have epigastric pain, which can indicate liver involvement or impending eclampsia.
Choice D reason: Vaginal discharge is not a sign of preeclampsia, but rather a normal occurrence of pregnancy, as the cervical glands secrete more mucus to protect the uterus from infection. A client with preeclampsia may have vaginal bleeding, which can indicate placental abruption or disseminated intravascular coagulation.
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Correct Answer is C
Explanation
Choice A reason: A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions does not need to be reported to the provider immediately, because it may indicate preterm labor, which is not an emergency. The nurse should assess the client's cervix, fetal heart rate, and hydration status, and administer tocolytic therapy as prescribed.
Choice B reason: A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes does not need to be reported to the provider immediately, because they are expected findings in mild preeclampsia. The nurse should monitor the client's blood pressure, urine output, and reflexes, and administer antihypertensive and anticonvulsant medications as prescribed.
Choice C reason: A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache needs to be reported to the provider immediately, because they are signs of severe preeclampsia or impending eclampsia. The nurse should prepare the client for delivery, as it is the only definitive treatment for preeclampsia.
Choice D reason: A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors does not need to be reported to the provider immediately, because they are a common and mild side effect of terbutaline, a beta-adrenergic agonist that relaxes the uterine smooth muscle. The nurse should reassure the client that the tremors are temporary and harmless, and monitor the client's pulse and blood pressure.
Correct Answer is C
Explanation
Choice A reason: "I know I am at increased risk to develop type 2 diabetes." is a correct statement, because it indicates that the client understands the long-term implications of gestational diabetes. The client should be aware that gestational diabetes increases the risk of developing type 2 diabetes later in life, and that she should have regular screening and follow-up.
Choice B reason: "I will take my glyburide daily with breakfast." is a correct statement, because it indicates that the client understands the medication regimen for gestational diabetes. The client should take glyburide, a sulfonylurea that lowers blood glucose levels, as prescribed by the provider, and monitor her blood glucose levels before and after meals.
Choice C reason: "I will reduce my exercise schedule to 3 days a week." is an incorrect statement, because it indicates that the client does not understand the importance of physical activity for gestational diabetes. The client should exercise at least 30 minutes a day, 5 days a week, unless contraindicated by the provider. Exercise can help improve insulin sensitivity, lower blood glucose levels, and prevent excessive weight gain.
Choice D reason: "I should limit my carbohydrates to 50% of caloric intake." is a correct statement, because it indicates that the client understands the dietary guidelines for gestational diabetes. The client should consume a balanced diet that provides adequate but not excessive amounts of carbohydrates, protein, and fat, and that is consistent in carbohydrate intake throughout the day.
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