A nurse is assessing a pregnant client at 36 weeks gestation with a pre-pregnancy BMI of 32 kg/m². Which assessment finding would be the priority concern for this client?

Hypertension is a priority concern due to increased risk of preeclampsia in obese pregnant clients. Other findings are normal or less urgent.

Core Nursing Explanation Key Concept Analysis: This question assesses the nurse's ability to identify the highest-priority risk for a pregnant client with obesity. The core theme is risk assessment and prioritization in prenatal care. A pre-pregnancy BMI of 32 kg/m² classifies the client as having Obesity (Class I), which is a significant risk factor for developing hypertensive disorders of pregnancy, particularly Preeclampsia. Preeclampsia is a leading cause of maternal and fetal morbidity and mortality, characterized by new-onset hypertension after 20 weeks gestation, often with proteinuria. The priority in nursing assessment is to recognize early signs of this dangerous condition.

Answer Rationale: A blood pressure reading of 150/95 mmHg at 36 weeks gestation is a critical finding. According to diagnostic criteria, hypertension in pregnancy is defined as systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg on two occasions at least 4 hours apart. A single reading this high, especially in a high-risk client, warrants immediate and urgent follow-up. Key Point! This finding takes priority because it is a potential indicator of preeclampsia, which can rapidly progress to eclampsia (seizures) or HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), threatening both mother and fetus.

Distractor Analysis:
② Fundal height measuring 26 cm: At 36 weeks, the expected fundal height is typically close to the gestational age in weeks (±2 cm). A measurement of 26 cm would suggest a potential for Intrauterine Growth Restriction (IUGR) or incorrect dating, which is concerning but not an immediate life-threatening emergency like severe hypertension. This requires investigation but is not the top priority in this scenario.
③ Fetal heart rate of 145 beats per minute: A fetal heart rate (FHR) between 110-160 beats per minute is considered normal. This is a reassuring finding and does not indicate an acute problem.
④ Weight gain of 18 pounds since conception: For a client with a pre-pregnancy BMI in the obese range, the recommended total weight gain is 11-20 pounds. An 18-pound gain at 36 weeks falls within this guideline and is therefore an expected finding, not a concern.

Related Concepts: This question integrates knowledge of maternal risk factors, normal prenatal assessment parameters, and the nursing process (assessment and analysis). It tests the ability to apply the ABC (Airway, Breathing, Circulation) priority framework and its maternal adaptation, where conditions affecting maternal hemodynamic stability (like hypertension) are often top priority.

Nursing Clinical Practice Guide Clinical Scenario: You are a nurse in a prenatal clinic. Ms. Johnson, a 29-year-old G2P1 at 36 weeks gestation, comes for her routine check-up. Her chart notes a pre-pregnancy BMI of 32. During your assessment, you obtain a blood pressure of 150/95 mmHg. She reports a mild headache but denies visual changes, epigastric pain, or sudden swelling.

Nursing Intervention Strategy:

1. Immediate Assessment: Stay calm. Have the client rest in a left lateral recumbent position for 10-15 minutes and recheck the BP in the opposite arm. Assess for other symptoms of preeclampsia: headache, visual disturbances (scotomata), right upper quadrant/epigastric pain, hyperreflexia, clonus, and severe edema (especially facial/hand).
2. Urgent Notification: Immediately report the elevated BP and any associated symptoms to the healthcare provider (physician or midwife).
3. Diagnostic Support: Anticipate and prepare for orders such as urine dipstick for protein, 24-hour urine collection for total protein, blood tests (CBC, liver enzymes, creatinine, platelet count), and possibly a non-stress test (NST) or biophysical profile (BPP) to assess fetal well-being.
4. Patient Education & Monitoring: Educate the client on danger signs (severe headache, vision changes, pain) and instruct her to go to Labor & Delivery immediately if they occur. Discuss the plan as directed by the provider, which may include more frequent monitoring, possible antihypertensive medication (e.g., labetalol, nifedipine), or plans for delivery.

Patient Safety and Precautions: Never dismiss a single high BP reading in a high-risk patient. Avoid taking BP on an arm with an AV fistula or recent trauma. Ensure the cuff size is appropriate (a too-small cuff will falsely elevate readings). Monitor for signs of impending eclampsia, which requires immediate intervention with magnesium sulfate to prevent seizures.

Nursing Procedure & Medication Flow Procedure for Managing Suspected Preeclampsia: 1. Positioning: Place patient in left lateral position to improve venous return and placental perfusion. 2. Vital Signs & Neurological Checks: Monitor BP frequently (every 5-15 minutes if severe). Assess deep tendon reflexes (DTRs) and check for clonus. 3. Seizure Precautions: Maintain a quiet, dimly lit environment. Have emergency equipment (suction, oxygen, magnesium sulfate) readily available at the bedside. 4. Medication Administration - Magnesium Sulfate: If ordered for seizure prophylaxis, administer via IV pump. Monitor closely for toxicity: Loss of patellar reflexes is the first sign of toxicity (therapeutic level: 4-8 mg/dL). Respiratory depression (