Nursing interventions and Management
Nursing interventions and Management ( 5 Questions)
A nurse is monitoring a client with gestational hypertension for signs of fluid retention and edema.
Which of the following assessments would be most helpful?
Measuring abdominal girth daily is not a reliable indicator of fluid retention or edema, as it can also be affected by fetal growth, uterine size, and maternal fat distribution.
Checking for pitting edema in the lower extremities is not a specific sign of preeclampsia, as it can also occur in normal pregnancies due to increased blood volume and venous pressure.
Weight gain and edema are common signs of fluid retention and preeclampsia, a serious complication of gestational hypertension. Weighing the client daily at the same time can help monitor the fluid status and detect any sudden changes that may indicate worsening preeclampsia.
Auscultating lung sounds for crackles is not a helpful assessment for fluid retention and edema, as it is a late sign of pulmonary edema, which is a rare but life-threatening complication of severe preeclampsia.
The correct answer is choice C. Weighing the client daily at the same time. This is because weight gain and edema are common signs of fluid retention and preeclampsia, a serious complication of gestational hypertension. Weighing the client daily at the same time can help monitor the fluid status and detect any sudden changes that may indicate worsening preeclampsia.
Choice A is wrong because measuring abdominal girth daily is not a reliable indicator of fluid retention or edema, as it can also be affected by fetal growth, uterine size, and maternal fat distribution.
Choice B is wrong because checking for pitting edema in the lower extremities is not a specific sign of preeclampsia, as it can also occur in normal pregnancies due to increased blood volume and venous pressure.
Choice D is wrong because auscultating lung sounds for crackles is not a helpful assessment for fluid retention and edema, as it is a late sign of pulmonary edema, which is a rare but life-threatening complication of severe preeclampsia.
