The nurse is performing an assessment on a client who is suspected of having preeclampsia.
Which question would be appropriate for the nurse to ask to determine if the client has preeclampsia?
The nurse is performing an assessment on a client who is suspected of having preeclampsia.
Which question would be appropriate for the nurse to ask to determine if the client has preeclampsia?
A. “Does the light bother you?”
[71%]
B. "Are you having any back aches?"
[12%]
C. "Are you having any vaginal discharge?"
[6%]
D. "Are you noticing any bleeding in your gums?"
[10%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Antepartum
Client Need
Test Plan
Reduction of Risk Potential
Related Topic
Potential for Alterations in Body Systems
Item Type
Item Type
Application
Explanation
Choice A is correct. Targeting an assessment to a client who is suspected of having preeclampsia would include questions such as "Does the light bother you?" because headache and photosensitivity are clinical manifestations associated with this condition. Other pertinent questions that are useful in determining if the client may have preeclampsia include - "Do you have any abdominal pain?" as severe preeclampsia may cause epigastric pain. "Is your vision blurred?" as blurred vision may support a diagnosis of preeclampsia.
Choice B is incorrect. Backaches are expected in pregnancy because lumbar lordosis and relaxed ligaments contribute to the problem. This assessment question would not be appropriate because it is not specific to preeclampsia.
Choice C is incorrect. Vaginal discharge is not a finding in preeclampsia. Vaginal discharge can have an array of causes, such as maternal infection or a miscarriage.
Choice D is incorrect. Gum tenderness and bleeding are maternal changes during pregnancy. Gums may be red, tender, and edematous and may bleed more easily.
Related Videos
2 Key Topics
Preeclampsia
28.5 Infection & Complication Risks
Additional Info
✓ Preeclampsia is a serious maternal complication. Its pathophysiology is not fully understood.
✓ Manifestations of preeclampsia can be serious and include high blood pressure and proteinuria. The client may endure headaches and photosensitivity coupled with edema.
✓ If the preeclampsia worsens, the blood pressure will increase (160/110 mm Hg), and more protein in the urine.
✓ Additionally, the client may start to get more symptoms, such as epigastric pain, elevated liver enzymes, anemia, and thrombocytopenia. These symptoms, along with a significant increase in blood pressure, are considered severe preeclampsia.
