A nurse is caring for a client who is pregnant. Exhibits The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
Explanation & Rationale
Rationale: A. Urine ketones is negative; ketonuria would suggest dehydration or malnutrition, which are not evident here. B. A severe, persistent headache unrelieved by acetaminophen is a classic warning sign of preeclampsia, indicating possible cerebral involvement due to increased blood pressure and endothelial dysfunction. C. The client’s report of decreased fetal movement suggests uteroplacental insufficiency secondary to hypertension, which can lead to fetal hypoxia or growth restriction. This finding requires immediate evaluation of fetal well-being. D. Gravida 3/parity 2 is expected and not a complication. E. A BP of 162/112 mm Hg is markedly elevated, meeting the diagnostic criteria for severe preeclampsia (≥160 systolic or ≥110 diastolic). This finding indicates maternal and fetal risk for seizures, stroke, and placental abruption. F. Respiratory rate of 16/min is within the normal range and not concerning. G. A 3+ proteinuria indicates significant protein loss due to glomerular damage, another defining feature of preeclampsia. Combined with hypertension, this confirms a major obstetric emergency.