The perinatal nurse is caring for a woman at 26 weeks' gestation who has a history of hypertension that has been well controlled. Today she presents with a blood pressure of 156/102 mm Hg and she has 2+ protein on urine dipstick

Question

Which initial action by the nurse is most appropriate?
A.
Arrange admission to the high-risk OB unit.
B.
Instruct the woman on strict bedrest.
C.
Obtain a clean-catch urine sample.
D.
Prepare to administer IV anti-hypertensives.

Answer 1

ANS: C
Preeclampsia can occur in a woman who has chronic hypertension. This woman has the characteristics of hypertension after a period of good control and proteinuria of at least 2+ on dipstick (100 mg/dL). The nurse needs to ensure protein levels are assessed in two samples at least 4 hours apart and ensure the woman has no signs of a urinary tract infection, as protein can occur in a sample of infected urine. The nurse should obtain a clean-catch urine sample to send to the laboratory for analysis. Asymptomatic UTI can occur in up to 11% of pregnant women, so assessing for signs and symptoms may not be accurate. The woman does not need admission to the high-risk OB unit, strict bedrest, or IV anti-hypertensives at this point.