Maternity Nursing: Antepartum Q 12
A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for preeclampsia. The nurse checks the client for which specific signs of preeclampsia? Select all that apply.
A. Elevated blood pressure
B. Negative urinary protein
C. Facial edema
D. Increased respirations
E. Polydipsia
Correct Answer: A & C. Elevated blood pressure and facial edema.
The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia.
Option A: Preeclampsia is defined as the presence of (1) a systolic blood pressure (SBP) greater than or equal to 140 mm Hg or a diastolic blood pressure (DBP) greater than or equal to 90 mm Hg or higher, on two occasions at least 4 hours apart in a previously normotensive patient, OR (2) an SBP greater than or equal to 160 mm Hg or a DBP greater than or equal to 110 mm Hg or higher.
Option B: In addition to the blood pressure criteria, proteinuria of greater than or equal to 0.3 grams in a 24-hour urine specimen, a protein (mg/dL)/creatinine (mg/dL) ratio of 0.3 or higher, or a urine dipstick protein of 1+ (if a quantitative measurement is unavailable) is required to diagnose preeclampsia.
Option C: Edema exists in many pregnant women, but a sudden increase in edema or facial edema is suggestive of preeclampsia. The edema of preeclampsia occurs by a distinct mechanism that is similar to that of angioneurotic edema.
Option D: Shortness of breath, a racing pulse, mental confusion, a heightened sense of anxiety, and a sense of impending doom can be symptoms of preeclampsia. If these symptoms are new to you, they could indicate an elevated blood pressure, or more rarely, fluid collecting in your lungs (pulmonary edema).
Option E: Primary polydipsia (PP) is a condition where there is excess consumption of fluids leading to polyuria with diluted urine and, ultimately, hyponatremia.