At 0600 Jennie is brought to the Labor and Delivery triage area by her sister. The client complains of a pounding headache for the last 12 hours unrelieved by acetaminophen (Tylenol), swollen hands and face for 2 days, and epigastric pain described as bad heartburn. Her sister tells the nurse, "I felt like that when I had toxemia during my pregnancy." Admission assessment by the nurse reveals: today's weight 182 pounds, T 99.1° F, P 76, R 22, BP 138/88, 4+ pitting edema, and 3+ protein in the urine. Heart rate is regular, and lung sounds are clear. Deep tendon reflexes (DTRs) are 3+ biceps and triceps and 4+ patellar with 1 beat of ankle clonus. The nurse applies the external fetal monitor, which shows a baseline fetal heart rate of 130, absent variability, positive for accelerations, no decelerations, and no contractions. The nurse also performs a vaginal examination and finds that the cervix is 1 cm dilated and 50% effaced, with the fetal head at a -2 station.
In reviewing Jennie's history, the nurse is correct in concluding that Jennie is in jeopardy of developing a hypertensive disorder because of her age (15). Which other factors add to Jennie's risk of developing preeclampsia? A) Molar pregnancy, history of preeclampsia in previous pregnancy. INCORRECT
While all of these are risk factors for preeclampsia, Jennie has no indications of a molar pregnancy (first trimester vaginal bleeding, size/date discrepancy, or excessive nausea and vomiting), nor has she had any previous pregnancies (gravida 1).
B) Gravidity, familial history.
Jennie is under 17 years of age, is pregnant for the 1st time, and has a sister with a history of toxemia, which is an old term for preeclampsia that some clients may still use.
C) History of pounding headache, low socioeconomic status.
While age and low socioeconomic status (SES) are risk factors, Jennie's SES is unknown. A pounding headache is a symptom, not a risk factor.
D) Low socioeconomic status (SES), history of pedal edema.
Although age and low SES are risk factors, this client's SES is unknown. Pedal edema is common in pregnancy after 32-weeks.
To accurately assess this client's condition, what information from the prenatal record is most important for the nurse to obtain? A) Pattern and number of prenatal visits.
It is important to have early and consistent prenatal care, but this information will not help in the assessment of this client's condition.
B) Prenatal blood pressure readings.
The client's BP (138/88) is below the guideline that indicates mild preeclampsia. Blood pressure parameters for mild preeclampsia include a reading of 140/90 taken on two occasions 6 hours apart. However, Jennie's reading is significant if it is an increase of 30 mm systolic or 15 mm diastolic from her prenatal levels, particularly in combination with proteinuria and hyperuricemia (uric acid of 6 mg/dl or more). Blood pressure usually remains the same during the first trimester. Both systolic and diastolic then decrease gradually up to 20-weeks gestation. At 20 weeks of gestation, the blood pressure begins to gradually increase and return to 1st trimester levels at term.
C) Prepregnancy weight.
The nurse should compare today's weight to Jennie's most recently obtained previous weight, not to the prepregnancy weight. A weight gain of >2 pounds per week is indicative of mild preeclampsia.
D) Jennie's Rh factor.
While the Rh factor of the mother is important in determining the need for prophylactic Rh immune globulin (RhoGAM) at 28-weeks and after birth, it is not the most important information at this time. All Rh negative women with negative Coomb's tests are given RhoGam prophylactically at 28-weeks, and then evaluated immediately after birth to determine if another dose of RhoGam is needed.
Pathophysiology of Preeclampsia
There is no definitive cause of preeclampsia, but the...
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