A nurse is assessing a pregnant woman at 32 weeks of gestation. The client reports experiencing severe swelling in her legs and sudden weight gain. Which of the following actions should the nurse take first?
A. Schedule a follow-up appointment to monitor the swelling.
B. Advise the client to elevate her legs and reduce salt intake.
C. Perform a thorough assessment of the client’s blood pressure and urine for protein.
D. Recommend the client increase her fluid intake and exercise more.
The Correct answer and Explanation is:
The correct answer is C. Perform a thorough assessment of the client’s blood pressure and urine for protein.
Explanation:
At 32 weeks of gestation, a pregnant woman presenting with severe swelling in her legs and sudden weight gain should prompt immediate and thorough assessment due to the potential risk of preeclampsia. Preeclampsia is a serious pregnancy complication characterized by high blood pressure and often protein in the urine. It can develop after 20 weeks of gestation and can lead to severe complications for both the mother and the baby if not managed properly.
Why Perform a Thorough Assessment of Blood Pressure and Urine First?
- Diagnostic Criteria for Preeclampsia: One of the hallmark signs of preeclampsia is elevated blood pressure. The condition is typically diagnosed if a pregnant woman has a blood pressure of 140/90 mmHg or higher on two separate occasions and has protein in her urine. Therefore, assessing these parameters helps determine whether preeclampsia is present, which requires immediate medical intervention.
- Differentiation of Conditions: While swelling (edema) and weight gain can be common in pregnancy, they can also be signs of preeclampsia or other conditions such as gestational hypertension. A thorough assessment helps in distinguishing between benign pregnancy-related swelling and a potentially serious condition.
- Guiding Further Action: If the assessment reveals high blood pressure and proteinuria, the nurse can escalate the situation to the healthcare provider for further evaluation and management. This may include additional diagnostic tests, close monitoring, and possibly interventions to ensure the health and safety of both the mother and the baby.
Other Options:
- A. Schedule a follow-up appointment: While follow-up is important, it does not address the immediate need for assessment and possible intervention for preeclampsia.
- B. Advise leg elevation and reduced salt intake: This might be appropriate if the swelling is due to benign causes but does not address the need for immediate evaluation of serious conditions.
- D. Increase fluid intake and exercise: These are general recommendations and may not address the urgent need to evaluate for preeclampsia or other serious conditions.
Thus, a thorough assessment of blood pressure and urine for protein is crucial for identifying potential preeclampsia and ensuring timely intervention.