Difficulty: Medium
Average Score: 95%
Simulated
Passage / Scenario
A nurse is caring for a client who is at 34 weeks of gestation. The client has a medical history of gestational diabetes, preeclampsia with previous pregnancy, and chronic hypertension for 5 years. The client's vital signs are: BP: 170/104 mm Hg, Pulse: 89/min, Respirations: 20/min, Temperature: 98.8°F (37.1°C) Oral, Oxygen saturation: 97% room air. The client's physical examination shows: Respirations even and unlabored, Awake, alert, and oriented to person, place, and time, Pedal pulse strong and regular bilaterally, 3+ edema in lower extremities.A nurse is caring for a client who is at 34 weeks of gestation. The client has a medical history of gestational diabetes, preeclampsia with previous pregnancy, and chronic hypertension for 5 years. The client's vital signs are: BP: 170/104 mm Hg, Pulse: 89/min, Respirations: 20/min, Temperature: 98.8°F (37.1°C) Oral, Oxygen saturation: 97% room air. The client's physical examination shows: Respirations even and unlabored, Awake, alert, and oriented to person, place, and time, Pedal pulse strong and regular bilaterally, 3+ edema in lower extremities. What are the two most important nursing diagnoses for this client?
Correct answer
A, B
Rationale
Risk for injury due to seizures is critical in severe preeclampsia, as seizures can cause maternal and fetal harm. Impaired gas exchange due to potential pulmonary edema is significant given the client's fluid overload risk from high BP and edema.