NCLEX Question for Pregnancy-induced hypertension (PIH) Nursing Priority Goal

A teenage patient, 38 weeks gestation, is admitted with a diagnosis of pregnancy-induced hypertension (PIH). Data include:  blood pressure 160/100, generalized edema, weigh gain of 10 pounds in last 2 weeks, and proteinuria of +3; the patient is also complaining of a headache and nausea.  In planning care for this client, the nurse would set the following priority goal. The client will
 

a.    demonstrate a decreased blood pressure within 48 hours

b.    not experience a seizure prior to delivery.

c.    maintain a strict diet prior to delivery

d.    comply with medical and nutritional regimen.

Correct Answer: B. Preeclampsia may progress to eclampsia, the convulsive phase of PIH.  Symptoms that herald the progression include headache, visual disturbances, epigastric pain, nausea or vomiting, hyperreflexia, and oliguria; classical signs of PIH also intensify.
 

In this disorder, placental perfusion is already compromised, decreasing maternal blood pressure can further reduce perfusion and stress the fetus; if the diastolic pressure exceeds 110 mmHg, an antihypertensive drug maybe administered.
 

Weight gain in advancing PIH is an indication of progressive water retention and not a sign of an inappropriate diet; a weight gain exceeding 1.5 kg per week during the third trimester is a sign of PIH.
 

The signs described here are indicators of progressive PIH; the data do not support noncompliance.

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