Gestational Hypertension > Maternal & Newborn
Exam Review
Signs and symptoms
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is assessing a pregnant woman with gestational hypertension.
Which of the following symptoms would lead the nurse to suspect that the client has developed severe preeclampsia?
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.
A client with gestational hypertension reports severe headache.
What should the nurse do first?
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.
A nurse is caring for a client with gestational hypertension who reports chest pain and shortness of breath.
What should the nurse do first?
Explanation
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.
A client with gestational hypertension reports abdominal pain and tenderness.
What should the nurse do first?
Explanation
The correct answer is choice B. Assess blood pressure.The nurse should do this first because gestational hypertension is a condition that causes high blood pressure after 20 weeks of pregnancyand can lead to complications such as placental abruptionor preeclampsia.
Abdominal pain and tenderness can be signs of these complications, so the nurse should check the blood pressure to determine the severity of the situation and plan further interventions.
Choice A is wrong because administering acetaminophen may not relieve the pain and may mask other symptoms.
Choice C is wrong because visual disturbances are not the most urgent symptom to assess in this case.
Choice D is wrong because assessing for proteinuria is not the first priority, although it is important to diagnose preeclampsia.
A nurse is caring for a client with gestational hypertension who reports swelling of the face, hands or feet and decreased urine output or protein in urine.
What should the nurse do first?
Explanation
The correct answer is choice B. Assess blood pressure.The nurse should first assess the client’s blood pressure because gestational hypertension is a condition that causes high blood pressure after 20 weeks of pregnancyand can lead to complications such as preeclampsia and abruptio placentae.High blood pressure is a classic sign of preeclampsia, along with proteinuria, edema, headache and blurred vision.
Therefore, the nurse should monitor the client’s blood pressure closely and report any abnormal findings to the health care provider.
Choice A is wrong because administering acetaminophen is not indicated for gestational hypertension and may mask signs of infection or inflammation.
Choice C is wrong because assessing for visual disturbances is not the priority action for gestational hypertension.
Visual disturbances are a symptom of severe preeclampsia or eclampsia, which are more serious conditions that require immediate medical attention.
Choice D is wrong because assessing for proteinuria is not the first action for gestational hypertension.
Proteinuria is a sign of preeclampsia, which may develop from gestational hypertension, but it is not present in all cases.
The nurse should first assess the blood pressure and then check for proteinuria if indicated by the provider or protocol.
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