Question

A nurse is caring for a postpartum client.

Based on the nurse's assessment findings, which of the following conditions is the client at greatest risk for developing?
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

History and Physical
Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago
42 years old
Gravida 2, Para 1
History of hypertension
History of asthma
No antihypertensive medications during pregnancy.
Treatment plan included diet and exercise.

Nurses' Notes
1730:
Client is awake and alert.
Fundus is firm, midline, and 2 cm below the umbilicus.
Incision is intact, light amount of lochia rubra observed.
+2 pitting edema observed to bilateral lower extremities.
Reports headache pain as 3 on a scale of 0 to 10.
Reports headache and heartburn began about 1 hr ago.

Vital Signs
1730:
Blood pressure 152/105 mm Hg, Temperature 37.8° C (100° F), Pulse 70/min, Respiratory rate 20/min, Oxygen saturation 98%

Diagnostic Results
Admission laboratory values (48 hr ago):
Hgb 11 g/dL (greater than 11 g/dL)
Platelets 150,000/mm³ (150,000 to 400,000/mm³)
BUN 19 mg/dL (10 to 20 mg/dL)
Creatinine 1 mg/dL (0.5 to 1 mg/dL)
Aspartate aminotransferase (AST) 33 units/L (0 to 35 units/L)
Alanine aminotransferase (ALT) 32 units/L (4 to 36 units/L)

Urinalysis:
Color: pink-tinged
pH 6.2 mg/dL (4.6 to 8 mg/dL)
Specific gravity 1.022 (1.010 to 1.025)
Leukocyte esterase Negative (Negative)
Nitrite negative (Negative)
Protein 0 mg/dL (0 to 8 mg/dL)
Glucose negative (Negative)
Ketones none (None)
Bilirubin none (None)
Red blood cells: >20 (≤2)


The client is at greatest risk for developing
A. Endometritis
B. Hemorrhage
C. Preeclampsia
D. Venous thrombosis
E. Urinary tract infection

As evidenced by
A. Amount of lochia
B. Increased blood pressure
C. Temperature
D. Bilateral lower extremity edema
E. Urine analysis

Answer 1

The client is at greatest risk for preeclampsia, evidenced by increased blood pressure (152/105 mm Hg) and a reported headache after delivery.

Step-by-step explanation:

The client is at greatest risk for developing preeclampsia, as evidenced by increased blood pressure. Preeclampsia is characterized by new-onset hypertension after the 20th week of pregnancy, often accompanied by other signs such as proteinuria, severe headaches, changes in vision, and edema. In this case, the client's marked hypertension (152/105 mm Hg) after giving birth is a concerning indicator. Additionally, the client reports a headache, another symptom associated with preeclampsia, although no proteinuria is present. The presence of bilateral lower extremity edema could also support the diagnosis of preeclampsia, but in this scenario, the elevated blood pressure and reported headache are more indicative of this condition.