43. A client, who is 15 years old, gravida 1, para 0 at 26 weeks of gestation, is admitted to an obstetrics unit with a diagnosis of mild preeclampsia. She has a blood pressure of 138/88 mm Hg and 1+ protein on urine dipstick. Which assessment finding should indicate to a nurse that the client's condition is getting severe?
Test-Taking Tip
The key to this question is remembering that the most important difference between mild and severe preeclampsia is the amount of proteinuria.
Content Area: Maternity, Antepartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
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Answer 1 is incorrect because normal deep tendon reflexes are 2+. Answer 2 is incorrect because a blood pressure reading of 140/90 mm Hg indicates mild preeclampsia. Severe preeclampsia is when diastolic blood pressures consistently exceed 110 mm Hg. Answer 3 is correct because 3+ urine protein on dipstick is a symptom of severe preeclampsia and would indicate that the client's condition is worsening. Answer 4 is incorrect because dependent edema is a normal finding of pregnancy. Edema of the hands or face or pitting edema indicates a worsening of the disease.
