A nurse is caring for a newborn who is 30 minutes old in the newborn nursery.

Exhibits

The condition that poses the greatest risk to the newborn is

dropdown

due to

dropdown

.

Rationale for Correct Condition

Preeclampsia is characterized by hypertension (≥140/90 mm Hg) and proteinuria (≥300 mg/24 hr) or signs of systemic involvement such as headache and edema. The client’s elevated BP, significant proteinuria, headache, hyperreflexia, and pitting edema strongly indicate preeclampsia. The absence of seizures rules out eclampsia, and the gestational age excludes chronic hypertension with superimposed preeclampsia.

Rationale for Correct Actions

Magnesium sulfate prevents seizures by stabilizing neuronal excitability and reducing cerebral vasospasm. It also lowers BP by promoting vascular relaxation. External fetal monitoring detects fetal distress from utero-placental insufficiency caused by preeclampsia-related hypertension and endothelial dysfunction.

Rationale for Correct Parameters

Blood pressure reflects disease progression and response to antihypertensives. Severe hypertension increases the risk of cerebral hemorrhage and placental abruption. Deep tendon reflexes indicate neurological impairment. Hyperreflexia signals worsening preeclampsia, while absent reflexes may indicate magnesium toxicity.

Rationale for Incorrect Conditions

Gestational hypertension lacks proteinuria and systemic symptoms. Chronic hypertension with superimposed preeclampsia requires a pre-existing hypertensive diagnosis. Eclampsia involves seizures, which the client has not reported.

Rationale for Incorrect Actions

Ampicillin is not indicated without infection. Rh immune globulin is unnecessary without Rh incompatibility. Anticoagulants are not first-line for preeclampsia.

Rationale for Incorrect Parameters

Temperature is not directly related to preeclampsia. Petechiae are signs of coagulopathy, not primary indicators. Pruritus is irrelevant unless liver dysfunction is suspected.

Take-Home Points

• Preeclampsia involves multisystem dysfunction with endothelial damage.
• Magnesium sulfate prevents seizures but must be monitored for toxicity.
• Differentiation from gestational hypertension is crucial for management.
• Fetal monitoring is key to detecting early signs of compromise.

Choice A rationale

A urinary output of 30 mL/hr is within the normal range for an adult, indicating adequate kidney perfusion and hydration status postpartum. Normal urine output is typically considered to be greater than 30 mL/hr.

Choice B rationale

Headache pain rated a 6 on a scale of 0 to 10 is a common complaint postpartum, especially after spinal anesthesia. While it requires assessment and management, it is not necessarily a sign of immediate life-threatening complication. Postpartum headaches can be related to hormonal shifts, dehydration, or the spinal anesthesia itself.

Choice C rationale

A blood pressure of 100/70 mm Hg is within the normal postpartum range for many women. While a decrease from pre-pregnancy levels can occur, this reading does not indicate an immediate critical issue. Normal postpartum blood pressure generally stabilizes around pre-pregnancy levels within a few days.

Choice D rationale

A respiratory rate of 10 breaths per minute is below the normal adult range of 12 to 20 breaths per minute. This bradypnea could indicate respiratory depression, a potential complication of spinal anesthesia, especially if opioid analgesics have been administered. Immediate intervention is required to assess the cause and ensure adequate oxygenation.