(Select all that apply) A nurse is assessing a client who is 32 weeks pregnant and has a diagnosis of severe preeclampsia.
Which of the following findings should the nurse report to the provider immediately?
Epigastric pain
Blurred vision
Facial edema
Hyperreflexia
Oliguria
Correct Answer : A,B,D,E
The correct answer is choice A, B, D and E. These are all signs of severe preeclampsia that indicate organ damage and require immediate medical attention. According to Mayo Clinic, preeclampsia is a complication of pregnancy that causes high blood pressure, protein in the urine, or other signs of organ damage after 20 weeks of gestation.
Choice A is correct because epigastric pain can indicate liver damage or bleeding in the abdomen due to preeclampsia.
Choice B is correct because blurred vision or light sensitivity can indicate brain damage or increased pressure in the skull due to preeclampsia.
Choice C is wrong because facial edema is a common symptom of normal pregnancy and does not necessarily indicate preeclampsia.
Choice D is correct because hyperreflexia can indicate nervous system damage or increased pressure in the skull due to preeclampsia.
Choice E is correct because oliguria can indicate kidney damage or decreased blood flow to the kidneys due to preeclampsia.
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Related Questions
Correct Answer is C
Explanation
Encourage bed rest in a left lateral position.
This is because bed rest can lower blood pressure and improve blood flow to the placenta and the fetus.The left lateral position reduces pressure on the inferior vena cava, a large vein that carries blood from the lower body to the heart.
Choice A is wrong because magnesium sulfate is used to prevent seizures in severe preeclampsia or eclampsia, not mild preeclampsia.
Choice B is wrong because monitoring the fetal heart rate and movement is important, but not the priority for this client.
Choice D is wrong because educating the client about the signs of eclampsia is not urgent and may not prevent the progression of preeclampsia.Some signs of eclampsia are severe headaches, blurred vision, nausea, vomiting, abdominal pain and seizures.
Correct Answer is ["C","D"]
Explanation
The correct answer is choice C and D.Epigastric pain and decreased fetal movement are signs of severe pre-eclampsia that indicate damage to the liver and placenta respectively.These symptoms should be reported to the health care provider immediately as they may lead to serious complications such as eclampsia, HELLP syndrome, placental abruption or fetal growth restriction.
Choice A is wrong because sudden weight gain is a common symptom of mild pre-eclampsia that does not necessarily require immediate attention.However, it should be monitored regularly along with blood pressure and urine protein levels.
Choice B is wrong because swelling of the face and hands is also a common symptom of mild pre-eclampsia that does not indicate severe organ damage.It may be caused by fluid retention or edema.
Choice E is wrong because vaginal bleeding is not a typical symptom of pre-eclampsia.It may be a sign of other pregnancy complications such as placenta previa, placental abruption or cervical infection.
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