QUESTION: "A 16-year-old unmarried client visiting the prenatal clinic at 32 weeks' gestation and currently weighing 140 pounds is being closely monitored for early signs of pregnancy-induced hypertension (PIH). The client is 5 feet, 2 inches tall and weighed 120 pounds before the pregnancy. Which of the following would be most important to assess? "
CHOICES
( O ) a.) Proteinuria.
( X ) b.) Small-for-gestational-age fetus.
( X ) c.) ABO incompatibility.
( X ) d.) Fluid intake.
RATIONALE: Because the client is being closely monitored for early signs of PIH, checking the urine for proteinuria is most important. Proteinuria, even in the absence of an elevated blood pressure, is indicative of PIH. Although adolescent pregnancy is associated with an increase in the number of small-for-gestational-age fetuses, this is not indicative of PIH. ABO incompatibility, occurring when the mother has type O blood and the fetus is type A, B, or AB blood, is not associated with PIH. Fluid intake is an important assessment for any pregnant client. However, it is not a primary indication of PIH. Edema of the hands and face is a more important indicator than fluid intake. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
