Signs and symptoms
Signs and symptoms ( 5 Questions)
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?
Administering acetaminophen is not indicated for gestational hypertension and may mask signs of infection or inflammation.
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 pregnancy and 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.
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.
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.
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 pregnancy and 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.