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