A nurse is assisting in the care of a client at 30 weeks of gestation who has a blood pressure reading of 160/116 mm Hg and 4 hours previously it was 164/114 mm Hg. The client reports blurred vision and a persistent frontal headache.
Which of the following complications of gestation should the nurse suspect?
Gestational hypertension.
Preeclampsia with severe features.
Preeclampsia without severe features.
Chronic hypertension.
The Correct Answer is B
Choice A rationale
Gestational hypertension is diagnosed when high blood pressure develops after 20 weeks of pregnancy without other symptoms of preeclampsia, such as proteinuria or end-organ dysfunction.
Choice B rationale
Preeclampsia with severe features includes high blood pressure, proteinuria, and symptoms like blurred vision and headaches. These indicate severe disease, which can endanger both the mother and the fetus if left untreated.
Choice C rationale
Preeclampsia without severe features involves high blood pressure and proteinuria but without the additional severe symptoms like blurred vision and headache.
Choice D rationale
Chronic hypertension refers to high blood pressure that was present before pregnancy or diagnosed before 20 weeks of gestation. It does not typically present with acute symptoms like blurred vision and headache that develop suddenly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
One parity indicates one delivery at a viable gestational age, which is not accurate for this client.
Choice B rationale
Two parity is correct as the client has delivered twins (considered one parity) at 36 weeks, which counts as one delivery at a viable gestational age.
Choice C rationale
Three parity is incorrect because the previous pregnancies did not result in three separate viable deliveries.
Choice D rationale
Four parity is incorrect as the client’s history includes one viable delivery (twins) and does not account for four separate viable births. .
Correct Answer is A
Explanation
Choice A rationale
Checking the fetal heart rate pattern is the priority after an amniotomy. This procedure involves breaking the amniotic sac, which can lead to changes in the fetal heart rate. Immediate assessment ensures the fetus is not in distress.
Choice B rationale
Evaluating for signs of infection is essential post-procedure, but not the immediate priority. Infection signs develop over time, while fetal distress can occur immediately.
Choice C rationale
Observing the color and consistency of amniotic fluid is important for identifying meconium-stained fluid, but it is not as immediately crucial as ensuring fetal well-being.
Choice D rationale
Taking the client's temperature can help monitor for infection later, but it is not the immediate concern following amniotomy. The primary concern is the fetal response.
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