Nokea
A pregnant patient at 36 weeks gestation reports sudden swelling of the face and hands. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A: Monitor the patient's blood pressure and check for signs of preeclampsia. At 36 weeks gestation, sudden swelling of the face and hands can indicate preeclampsia, a serious condition characterized by high blood pressure and proteinuria in pregnancy. Monitoring blood pressure and assessing for other signs of preeclampsia, such as headache or vision changes, is crucial for timely diagnosis and intervention to prevent complications for both the mother and baby.
Summary:
B: Instructing the patient to rest and elevate her feet may provide some relief for swelling but does not address the underlying potential issue of preeclampsia.
C: Recommending increased water intake may not be appropriate if the swelling is due to preeclampsia and can worsen the condition.
D: Administering diuretics without proper assessment and diagnosis of preeclampsia can be harmful and is not the initial priority action.