The perinatal nurse is caring for a woman at 26 weeks' gestation who has a history of hypertension that has been well controlled.Today she presents with a blood pressure of 156/102 mm Hg and she has 2+ protein on urine dipstick.Which initial action by the nurse is most appropriate?

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Quizplus · Accepted Answer

Preeclampsia can occur in a woman who has chronic hypertension.This woman has the characteristics of hypertension after a period of good control and proteinuria of at least 2+ on dipstick (100 mg/dL).The nurse needs to ensure protein levels are assessed in two samples at least 4 hours apart and ensure the woman has no signs of a urinary tract infection,as protein can occur in a sample of infected urine.The nurse should obtain a clean-catch urine sample to send to the laboratory for analysis.Asymptomatic UTI can occur in up to 11% of pregnant women,so assessing for signs and symptoms may not be accurate.The woman does not need admission to the high-risk OB unit,strict bedrest,or IV anti-hypertensives at this point.

The Perinatal Nurse Is Caring for a Woman at 26