Question

A 25-week-gestation client presents with a blood pressure of 142/90, pulse 78, no edema, and urine negative for protein. What would the nurse do next?

a. Initiate antihypertensive medication

b. Document the findings as normal

c. Repeat blood pressure measurement in 15 minutes

d. Assess for other signs of preeclampsia

Answer 1

The nurse would assess for other signs of preeclampsia.

Step-by-step explanation:

In this scenario, the nurse would assess for other signs of preeclampsia. Preeclampsia is a hypertensive disorder that can occur during pregnancy and is characterized by high blood pressure, proteinuria (protein in the urine), and sometimes edema. While the blood pressure measurement of 142/90 is elevated, it is not enough evidence to immediately initiate antihypertensive medication. Instead, the nurse should further assess the client for other signs and symptoms of preeclampsia to determine the appropriate course of action.