A woman who is 26 weeks pregnant has a blood pressure of 158/100 mm Hg. Which action by the nurse is most appropriate?
A.
Assess the woman's risk for other cardiovascular problems.
B.
Have her rest for 20 minutes, then reassess her blood pressure.
C.
Obtain a urine dipstick for proteinuria and assess for headache.
D.
Prepare to teach the woman about anti-hypertensive medication.
ANS: C
Preeclampsia is defined as a blood pressure greater than 140/90 mm Hg after 20 weeks' gestation accompanied by proteinuria. Other signs and symptoms include headache, visual changes, and edema. The nurse should suspect this condition and confirm it with a urine test for protein and by asking about the other symptoms. Assessing for other cardiovascular risk problems and teaching about anti-hypertensive medications are not warranted in this situation.
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