The nurse in the antepartum clinic assesses a client at 31 weeks gestation, reporting swelling of the face, hands and a frontal headache. Based on these findings, the nurse should do which of the following?
The nurse in the antepartum clinic assesses a client at 31 weeks gestation, reporting swelling of the face, hands and a frontal headache. Based on these findings, the nurse should do which of the following?
A. determine the fundal height.
[3%]
B. obtain vital signs.
[86%]
C. perform Leopold Maneuvers.
[3%]
D. insert an indwelling urinary catheter.
[8%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Antepartum
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Application
Explanation
Choice B is correct. The client's described symptoms, including facial and hand swelling and a frontal headache, may suggest preeclampsia, a severe pregnancy complication marked by elevated blood pressure and protein in the urine. Assessing vital signs, such as blood pressure, is crucial to understanding the client's status and deciding whether additional investigation or action is required.
Choice A is incorrect. Determining fundal height is important for assessing fetal growth and position, it does not directly address the client's current concerns of swelling and headache.
Choice C is incorrect. Leopold Maneuvers are used to determine fetal position and presentation, typically during the third trimester of pregnancy. This does not address the client's reported symptoms of swelling and headache.
Choice D is incorrect. Inserting an indwelling urinary catheter is not indicated based solely on the client's reported symptoms of swelling and headache. This action may be too invasive and unnecessary,, as the client's symptoms are more suggestive of a potential complication like preeclampsia.
Learning Objective
Understand that preeclampsia can develop anytime up to 6 weeks postpartum. Recognize the signs that need immediate attention.
Related Videos
4 Key Topics
Preeclampsia
28.5 Infection & Complication Risks
Nursing Process (ADPIE)
15.6 Prioritization Part 2
Additional Info
✓ Preeclampsia can develop after 20 gestational weeks.
✓ Clinical features of preeclampsia include:
- Blood pressure above 140/90 mmHg
- Proteinuria
- Swelling (usually in the hands and face).
Signs of Preeclampsia
