A nurse is assessing a pregnant woman with gestational ...

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A nurse is assessing a pregnant woman with gestational hypertension. Which of the following 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

Question 2

After learning about the need for a cesarean birth, the pregnant patient begins to cry and hyperventilate. Which nursing diagnosis should the nurse use to guide the care that the patient needs at this time?
 
  A) Fear related to impending surgery
  B) Risk for infection related to a surgical incision
  C) Powerlessness related to medical need for cesarean birth
  D) Risk for impaired parent/infant attachment related to unplanned method of birth

[kiamars2010]

Answer to Question 1

D
Feedback:
Severe preeclampsia is characterized by blood pressure over 160/110 mm Hg, urine protein levels greater than 500 mg/24 hours and hyperreflexia. Mild facial edema is associated with mild preeclampsia.

Answer to Question 2

A
Feedback:
The patient's emotional response after learning about a cesarean birth is most likely fear. The nurse should use the diagnosis of fear related to impending surgery to guide interventions at this time. The patient's emotional response is not likely because of a risk of infection, powerlessness, or a risk for impaired parent/infant attachment.