Question

during the initial assessment of a laboring client, the nurse notes the following: blood pressure 160/110 mm hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, reflexes 3/ 4 with 2 beat clonus. urine specimen reveals 3 protein, negative sugar and ketones. based on these findings, a nurse should expect the client to have which complaints?

Answer 1

Answer: headache, blurred vision, and facial and extremity swelling

Explanation: The client is exhibiting signs of preeclampsia. In addition to hypertension and hyperreflexia, most clients with preeclampsia have edema. Headache and blurred vision are indications of the effects of the hypertension. Abdominal pain, urinary frequency, diaphoresis, nystagmus, dizziness, lethargy, chest pain, and shortness of breath are inconsistent with a diagnosis of preeclampsia.