A nurse is caring for a client with gestational hypertension who reports chest pain and shortness of breath.
What should the nurse do first?
Administer oxygen
Assess blood pressure
Assess for visual disturbances
Assess for proteinuria
The Correct Answer is A
The correct answer is choice A. Administer oxygen.
The client is experiencing signs of pulmonary edema, which is a complication of gestational hypertension.
Oxygen therapy can help improve oxygenation and reduce the workload of the heart.
The nurse should also monitor the client’s vital signs, urine output, and magnesium sulfate level.
Choice B. Assess blood pressure.
This is an important action, but not the first priority.
The nurse should assess blood pressure after administering oxygen and stabilizing the client.
Choice C. Assess for visual disturbances.
This is a symptom of severe preeclampsia, but not an immediate threat to the client’s life.
The nurse should assess for visual disturbances as part of the ongoing evaluation of the client’s condition.
Choice D. Assess for proteinuria.
This is a diagnostic criterion for preeclampsia, but not a priority action in this situation.
The nurse should assess for proteinuria as part of the routine urinalysis.
Normal ranges for blood pressure are less than 140/90 mm Hg, and for proteinuria are less than 300 mg/24 hours.
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Related Questions
Correct Answer is D
Explanation
Hyperreflexia is a sign of severe preeclampsia, which is a complication of gestational hypertension that can affect the mother and the fetus.Hyperreflexia means having exaggerated reflexes that can cause muscle spasms or jerks.It can indicate increased nervous system activity due to high blood pressure.
A. Urine protein 300 mg/24 hours.This statement is wrong because urine protein 300 mg/24 hours is within the normal range for pregnant women.Proteinuria, which is a sign of preeclampsia, is defined as urine protein more than 300 mg/24 hours.
B. Blood pressure 150/96 mm Hg.
This statement is wrong because blood pressure 150/96 mm Hg is not high enough to indicate severe preeclampsia.Severe preeclampsia is diagnosed when blood pressure is 160/110 mm Hg or higher on two occasions at least four hours apart.
C. Mild facial edema.This statement is wrong because mild facial edema is a common symptom of pregnancy and not specific to preeclampsia.Severe preeclampsia may cause sudden and severe swelling in the face, hands, or feet.
Correct Answer is B
Explanation
The correct answer is choice B. Assess blood pressure.This is because a severe headache can be a sign of elevated blood pressure, which can lead to preeclampsia and other complications in pregnancy.
Assessing blood pressure is the first step to determine the severity of the condition and the need for further interventions.
Choice A is wrong because administering acetaminophen may not address the underlying cause of the headache and may mask other symptoms.
Choice C is wrong because assessing for visual disturbances is not the first priority, although it can be a serious symptom of preeclampsia.
Blood pressure should be assessed first to determine the risk of eclampsia and other adverse outcomes.
Choice D is wrong because assessing for proteinuria is not the first priority, although it can be a diagnostic criterion for preeclampsia.
Blood pressure should be assessed first to determine the severity of the condition and the need for further interventions.
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