A 17-year-old primigravida has gained 4 pounds since her last prenatal visit. Her blood pressure is 140/92 mm Hg. The most important nursing action is to:
a. advise her to cut down on fast foods that are high in fat.
b. caution her to avoid salty foods and to return in 2 weeks.
c. assess weight gain, location of edema, and urine for protein.
d. recommend she stay home from school for a few days to reduce stress.
ANS: C
The nurse should further assess the client for hypertension, generalized edema, and proteinuria, which are classic signs of pregnancy-induced hypertension. Cutting down on fast foods will not relieve the symptoms of pregnancy-induced hypertension. She is at risk for pregnancy-induced hypertension and should be evaluated at this visit. Rest may be the treatment at first, but she needs further assessment to determine if pregnancy-induced hypertension is the problem.
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