Which client in a prenatal clinic should the nurse assess first?

Question

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11ecbb05_cbf0_a944_b433_4d4c3f2cea13_MD0009_00 Gestational hypertension is new-onset high blood pressure (≥140/90 mm Hg) that occurs after 20 weeks gestation without proteinuria. The development of proteinuria with hypertension indicates preeclampsia, which may manifest with symptoms such as headache, visual disturbances, and facial swelling. This client is exhibiting symptoms of preeclampsia and should be assessed first (Option C). Complications of preeclampsia may include thrombocytopenia, liver dysfunction, and renal insufficiency. Clients with preeclampsia must be monitored closely for sudden worsening, which can lead to serious complications, including eclampsia and/or HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). (Option A) Backache and pelvic pressure are common discomforts of pregnancy. The enlarging uterus stretches the supporting ligaments and may cause increased backache. Fluid retention from increasing blood volume causes pelvic congestion, which may be reported as pelvic pressure. (Option B) Earache and sinus congestion are common discomforts during pregnancy that result from increased blood volume and fluid retention. This client should be assessed to rule out sinus and/or ear infection, but this is not the highest priority. (Option D) The increase in estrogen and progesterone during pregnancy often results in leukorrhea, a mucoid, white vaginal discharge. Pressure on the bladder from the fetal head during the third trimester may cause diminished bladder capacity and urinary frequency without dysuria. These are common and expected findings. Educational objective: The nurse should assess the client with symptoms of potentially serious complications first before assessing the remaining clients. Signs of hypertensive disorders during pregnancy may include headache and facial edema.

Which Client in a Prenatal Clinic Should the Nurse Assess