A nurse is caring for a 35-year-old female client who is at 37 weeks of gestation in the antepartum unit. Exhibits Complete the following sentence using the drop-down options: The nurse’s greatest concern is the client’s risk of developing dropdown related to dropdown and dropdown

The nurse’s greatest concern is the client’s risk of developing preeclampsia with severe features related to elevated blood pressure and proteinuria. Rationale for correct answers Preeclampsia with severe features is diagnosed when a pregnant client has blood pressure ≥160/110 mm Hg, as seen in this case (162/112 mm Hg), along with signs of end-organ damage, such as proteinuria, thrombocytopenia, and elevated liver enzymes. The client has proteinuria, as detected in urinalysis, and laboratory markers of potential organ dysfunction, including elevated AST, ALT, LDH, and creatinine, all supporting progression to severe disease. Elevated blood pressure is a hallmark of preeclampsia and places the client at risk for stroke, placental abruption, and fetal complications. Proteinuria (urinary excretion of excess protein due to endothelial dysfunction) confirms a worsening condition. Immediate interventions, including magnesium sulfate for seizure prevention and antihypertensives, are warranted. Rationale for incorrect Response 1 options Gestational hypertension: Unlike gestational hypertension, which is hypertension without proteinuria or organ dysfunction, this client meets criteria for severe preeclampsia, making gestational hypertension an incomplete diagnosis. Placental abruption: No vaginal bleeding or symptoms like sudden abdominal pain suggestive of placental separation. Chorioamnionitis: No fever or foul-smelling amniotic fluid, ruling out intrauterine infection. Rationale for incorrect Response 2 options Fetal distress: While late decelerations indicate uteroplacental insufficiency, the primary concern remains maternal preeclampsia, which secondarily leads to fetal distress. Oliguria: Though urine output is reduced, it is not the leading diagnostic criterion over hypertension and proteinuria. Contractions: Preterm labor is occurring, but contractions are not the main threat compared to severe preeclampsia risks. Rationale for incorrect Response 3 options Vaginal bleeding: No signs of bleeding, ruling out placental abruption or other hemorrhagic complications. Fever: No elevated temperature indicative of infection. Hypoxia: Oxygen saturation is normal (98%), and the primary issue relates to vascular dysfunction rather than respiratory compromise.