Question

A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational HTN. What finding should the nurse identify as the priority?

a. 480 mL urine output in 24 hrs
b. 1+ protein in the urine
c. +2 edema of the feet
d. BP 144/92

Answer 1

In a patient with mild gestational hypertension at 35 weeks of gestation, the priority concern is the elevated blood pressure (BP) of 144/92 due to the potential complications associated with hypertension during pregnancy.

Step-by-step explanation:

The priority finding a nurse should assess in a client at 35 weeks of gestation with mild gestational hypertension is a blood pressure (BP) of 144/92. This is because hypertension in pregnancy is a critical concern and can lead to serious complications such as pre-eclampsia or eclampsia, which are significant threats to maternal and fetal health. The other findings such as a 24-hour urine output of 480 mL, 1+ protein in the urine, and +2 edema of the feet are also signs of possible preeclampsia, but the elevated BP is the most immediate risk that could signify worsening of the condition. It is critical to control hypertension to reduce the risk of these complications.

For the emergency department case, a patient with a BP of 70/45, confusion, and complaints of thirst could be experiencing shock, potentially due to hypovolemia, which suggests lower than normal blood volume, hence low blood pressure, and could also point towards severe dehydration or blood loss.