A nurse is assessing a pregnant woman with gestational hypertension.
Which of the following symptoms would lead the nurse to suspect that the client has developed severe preeclampsia?
A.
Urine protein 300 mg/24 hours
B.
Blood pressure 150/96 mm Hg
C.
Mild facial edema
D.
Hyperreflexia
The Correct answer and Explanation is:
The correct answer is D. Hyperreflexia.
Explanation:
Gestational hypertension is characterized by elevated blood pressure that occurs after the 20th week of pregnancy. Severe preeclampsia is a more serious condition that can develop from gestational hypertension, and it is marked by more severe symptoms and potential complications.
1. Urine Protein 300 mg/24 hours: This level of proteinuria indicates a mild level of protein in the urine, which is consistent with gestational hypertension or mild preeclampsia but not necessarily severe preeclampsia. In severe preeclampsia, proteinuria is usually much higher, often exceeding 5 grams per 24 hours.
2. Blood Pressure 150/96 mm Hg: While elevated, this blood pressure reading indicates mild to moderate hypertension rather than severe preeclampsia. Severe preeclampsia is defined by blood pressure readings of 160/110 mm Hg or higher.
3. Mild Facial Edema: Edema is a common symptom of both gestational hypertension and preeclampsia. Mild facial edema alone does not indicate severe preeclampsia. Severe preeclampsia usually presents with more pronounced or widespread edema, including significant swelling in the hands and face.
4. Hyperreflexia: This is a key indicator of severe preeclampsia. Hyperreflexia refers to overactive or exaggerated reflexes, which occur due to increased neurological irritability associated with severe preeclampsia. This symptom suggests that the condition may be progressing and could lead to complications such as seizures (eclampsia). Hyperreflexia, along with other symptoms like severe headaches, visual disturbances, and epigastric pain, signals that the preeclampsia has become severe and requires immediate medical intervention.
In summary, hyperreflexia is a clinical sign that suggests the progression of preeclampsia from mild to severe, making it the most significant indicator among the options provided.