A nurse is caring for an adolescent client who is pregnant with their second child and is experiencing anxiety. Which of the following statements should the nurse make?

Rationale:

A. Blood pressure: The reading of 162/112 mm Hg meets the criteria for severe hypertension in pregnancy, which increases the risk of complications such as preeclampsia, placental abruption, and stroke.

B. Urine ketones: Ketones are negative, which rules out dehydration or starvation ketosis. Ketones would be more concerning if elevated alongside hyperemesis or gestational diabetes.

C. Fetal activity: Decreased fetal movement at 31 weeks may indicate fetal hypoxia or distress and requires urgent evaluation with nonstress testing or biophysical profiling.

D. Respiratory rate: The client’s respiratory rate of 16/min is within the normal range (12–20/min) and does not indicate respiratory distress or a complication.

E. Report of headache: A severe, persistent headache that is unrelieved by acetaminophen is a classic warning sign of central nervous system involvement in preeclampsia and may precede seizures (eclampsia).

F. Urine protein: The presence of 3+ proteinuria indicates significant renal involvement, supporting a diagnosis of preeclampsia, particularly when paired with hypertension and neurologic symptoms.

G. Gravida/parity: While a history of preterm birth is a known risk factor, her current symptoms point toward preeclampsia rather than complications directly linked to her obstetric history.

Rationale:

A. The client experiences self-doubt when making decisions: Indecisiveness and self-doubt are common symptoms of major depressive disorder and do not reflect improvement. They typically indicate ongoing low self-esteem and cognitive impairment.

B. The client exhibits a flat affect: A flat or blunted affect is a hallmark of depressive states. Persistence of this symptom suggests the depression is still significantly impacting the client’s emotional expression.

C. The client can express angry feelings: Being able to express emotions such as anger can indicate emotional engagement and increased energy, which are signs of clinical improvement in depression.

D. The client looks down when speaking to others: This behavior suggests ongoing feelings of worthlessness or poor self-confidence, commonly seen in depressive states and not indicative of recovery.