The prenatal clinic nurse monitored women for preeclampsia. All four women were in the clinic at the same time. Which one should the nurse see first?
Weight gain of 0.5 kg during the past 2 weeks
Pitting pedal edema at the end of the day
Blood pressure increase to 138/86 mm Hg
Dipstick value of 3+ for protein in her urine
The Correct Answer is D
Choice A) Weight gain of 0.5 kg during the past 2 weeks: This is a normal weight gain for a pregnant woman and does not indicate preeclampsia.
Choice B) Pitting pedal edema at the end of the day: This is a common symptom of pregnancy and does not necessarily indicate preeclampsia. It can be relieved by elevating the legs and wearing compression stockings.
Choice C) Blood pressure increase to 138/86 mm Hg: This is a mild elevation of blood pressure and does not meet the criteria for preeclampsia, which is defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher on two occasions at least four hours apart.
Choice D) Dipstick value of 3+ for protein in her urine: This is a sign of significant proteinuria, which is one of the main features of preeclampsia. Proteinuria is defined as a urinary protein excretion of 300 mg or more in 24 hours or a dipstick reading of 1+ or higher. A dipstick value of 3+ indicates severe proteinuria and requires immediate attention and treatment. This woman has the highest risk of developing complications from preeclampsia, such as eclampsia, HELLP syndrome, placental abruption, or fetal growth restriction . Therefore, she should be seen by the nurse first.

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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: This is incorrect because acetylsalicylic acid (ASA), also known as aspirin, is not a cure for preeclampsia, but a preventive measure. ASA may reduce the risk of preeclampsia in some high-risk women by inhibiting platelet aggregation and improving blood flow to the placenta. However, ASA is not recommended for all pregnant women, as it may have adverse effects on the mother and the fetus, such as bleeding, premature closure of the ductus arteriosus, or fetal growth restriction.
Choice B: This is the correct answer because delivery of the fetus is the only definitive treatment for preeclampsia, as it eliminates the source of the placental factors that cause the condition. Preeclampsia is a multisystem disorder characterized by hypertension, proteinuria, and edema that occurs after 20 weeks of gestation. It is caused by abnormal placentation and endothelial dysfunction that lead to vasoconstriction, inflammation, and coagulation.
Delivery of the fetus and the placenta resolves these abnormalities and restores normal maternal physiology.
Choice C: This is incorrect because antihypertensive medications are not a cure for preeclampsia, but a symptomatic management. Antihypertensive medications may lower the blood pressure and reduce the risk of maternal complications, such as stroke, seizure, or organ damage. However, antihypertensive medications do not address the underlying cause of preeclampsia and do not improve fetal outcomes. Moreover, some antihypertensive medications are contraindicated in pregnancy due to their teratogenic effects.
Choice D: This is incorrect because magnesium sulfate is not a cure for preeclampsia, but a prophylaxis for eclampsia. Eclampsia is a severe complication of preeclampsia that involves seizures and coma. Magnesium sulfate is an anticonvulsant that prevents or treats eclamptic seizures by stabilizing neuronal membranes and reducing cerebral edema. However, magnesium sulfate does not lower blood pressure or improve renal function in preeclamptic women. It also has side effects such as nausea, flushing, headache, or respiratory depression.

Correct Answer is D
Explanation
Choice A: This is incorrect because pointing out how lucky she is to have a healthy baby may invalidate her feelings and make her feel guilty or ashamed. The nurse should acknowledge and respect the client's emotions and avoid making judgments or comparisons.
Choice B: This is incorrect because assessing her for pain is not the first action that the nurse should take. Although pain may be a factor that contributes to the client's emotional state, it is not the primary cause of her crying. The nurse should first establish rapport and trust with the client and then assess her physical and psychological needs.
Choice C: This is incorrect because explaining that she is experiencing postpartum blues may be premature and inaccurate. Postpartum blues are mild and transient mood changes that occur in up to 80% of women within the first few days after childbirth. They are characterized by tearfulness, irritability, anxiety, and mood swings. However, the nurse should not assume that the client has postpartum blues without performing a thorough assessment and ruling out other possible causes of her crying, such as postpartum depression, anxiety, or trauma.
Choice D: This is the correct answer because allowing her time to express her feelings is the most appropriate and empathetic action that the nurse should take first. The nurse should listen actively and attentively to the client and provide emotional support and reassurance. The nurse should also use open-ended questions and reflective statements to facilitate communication and explore the client's concerns and coping strategies.
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