The nurse performs initial assessments of four clients in a prenatal clinic. Which client findings are abnormal and require further assessment?

Question

The nurse performs initial assessments of four clients in a prenatal clinic.  Which client findings are abnormal and require further assessment?

Quizplus · Accepted Answer

Physiologic decreases in systemic vascular resistance during pregnancy cause a steady, slight decrease in blood pressure (BP) beginning in the first trimester and reaching the lowest point around 24-32 weeks gestation. In the third trimester, BP gradually returns to pre-pregnancy baseline. Monitoring BP during pregnancy assists in the detection of hypertensive disorders of pregnancy (chronic hypertension, gestational hypertension, preeclampsia, eclampsia). Some clients with only mildly elevated BP may develop eclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). An increase in BP of ≥30 mm Hg systolic or ≥15 mm Hg diastolic over pre/early-pregnancy measurements, even in the absence of hypertension (ie, ≥140/90 mm Hg), is a deviation from normal physiologic BP responses in pregnancy and requires further assessment for other signs/symptoms (eg, proteinuria, headache, right upper quadrant pain) (Option D). (Option A) Early in the first trimester, minimal weight gain (ie, 1-4 lb [0.5-1.8 kg]) is expected for clients with a normal BMI. (Option B) Occasional headaches relieved by acetaminophen may be normal for some pregnant clients. Severe, frequent, or worsening headaches require further assessment. (Option C) Hyperemic gums are common in pregnancy and may be susceptible to mild bleeding during brushing. Gentle cleaning with a soft toothbrush may help prevent bleeding. Educational objective: Physiologic decreases in systemic vascular resistance cause a steady, slight decrease in blood pressure (BP) beginning in the first trimester and reaching its lowest point around 24-32 weeks gestation. An increase in BP of ≥30 mm Hg systolic or ≥15 mm Hg diastolic over pre/early-pregnancy measurements requires further assessment.

The Nurse Performs Initial Assessments of Four Clients in a Prenatal