NR 602 Week 7 Case Study Analysis Example

Case Study Analysis: J.T. at 34 Weeks With a Blood Pressure of 144/92, a Ranked Differential Carried by Gestational Age and the Test That Decides It

Student Name

College of Nursing, Chamberlain University

NR 602: Primary Care of the Childbearing and Childrearing Family Practicum

Instructor Name

Month Day, Year

Case Study Analysis: J.T. at 34 Weeks With a Blood Pressure of 144/92, a Ranked Differential Carried by Gestational Age and the Test That Decides It

The Case, Briefly

Blood pressure is measured at every prenatal visit precisely to catch this kind of change (US Preventive Services Task Force, 2023).

J.T., 31, at 34 weeks 1 day, previously normotensive (110/70 at booking, 118/74 at 30 weeks), measured 144/92 at a routine visit, and 142/90 on repeat after 15 minutes of rest. J.T. reports a mild headache since morning, relieved partly by acetaminophen, and more swelling of the hands this week. No visual changes, no upper abdominal pain, no shortness of breath. Fetal movements normal. Fundal height 32 cm. Urine dip: 1+ protein.

Findings With an Age Attached

A pressure of 144/92 would prompt a recheck in a few months in a nonpregnant adult. At 34 weeks, in a patient with normal pressures earlier in pregnancy, it is the central finding of the case.

New hypertension after 20 weeks narrows the possibilities. Chronic hypertension usually shows itself before 20 weeks; J.T.'s early readings were normal.

Fundal height of 32 cm at 34 weeks is 2 cm behind, at the edge of the expected range. In the context of new hypertension, it raises the possibility of slowed fetal growth.

1+ protein on a dip is a screening result, not a diagnosis; dips give false positives and negatives.

A Ranked Differential

1. Preeclampsia. New hypertension after 20 weeks with proteinuria on dip, headache and new hand swelling. If the protein is confirmed, or if certain laboratory abnormalities are present, the diagnosis is made even without proteinuria (American College of Obstetricians and Gynecologists, 2020). Most likely.

2. Gestational hypertension. New hypertension after 20 weeks without proteinuria or other features of preeclampsia. Possible if the dip is a false positive and laboratory tests are normal. About a quarter or more of patients with gestational hypertension go on to develop preeclampsia, so this is a step on the same path rather than a safe alternative.

3. Chronic hypertension, previously unrecognized. Unlikely: two normal readings earlier in pregnancy, including at booking.

4. Measurement error or white coat effect. Unlikely: two readings after rest, with symptoms and protein.

The Test That Decides

A urine protein to creatinine ratio. A ratio of 0.3 or higher confirms proteinuria and, with the blood pressure, makes the diagnosis preeclampsia. Sent with it: a complete blood count for platelets, serum creatinine and liver enzymes. Platelets below 100,000, creatinine above 1.1 mg/dL or doubled, or liver enzymes twice the upper limit would each mean preeclampsia with severe features, regardless of protein.

J.T.'s results, available the same afternoon: protein to creatinine ratio 0.42; platelets 188,000; creatinine 0.7; liver enzymes normal.

Diagnosis: preeclampsia without severe features at 34 weeks 1 day.

What Severe Features Would Change

A blood pressure of 160/110 or higher on two readings, a severe headache unrelieved by medication, visual disturbance, upper abdominal pain, low platelets, raised creatinine or liver enzymes, or fluid in the lungs would move J.T. into preeclampsia with severe features, which calls for hospital admission and, at 34 weeks or later, delivery.

A Plan for Both Patients

For J.T.: referred to labor and delivery for same-day assessment with the obstetric team, which confirmed the diagnosis and arranged outpatient management with twice-weekly visits, home blood pressure monitoring twice daily and weekly laboratory tests. Delivery is recommended at 37 weeks for preeclampsia without severe features, earlier if severe features develop (American College of Obstetricians and Gynecologists, 2020).

For the fetus: ultrasound for estimated fetal weight and amniotic fluid, given the fundal height lag; nonstress test twice weekly; daily movement counting by J.T.

Low-dose aspirin, recommended from 12 weeks for patients at high risk of preeclampsia, was not started in this pregnancy because J.T. had no high-risk factors at booking (US Preventive Services Task Force, 2021); in a future pregnancy, this preeclampsia would make J.T. eligible.

What J.T. Was Told

That preeclampsia is a condition of pregnancy that affects blood pressure and can affect the kidneys, liver and the baby's growth; that it can worsen quickly, which is why the warning signs matter; and that it ends after the baby and placenta are delivered. J.T. was given written warning signs and the labor and delivery number.

Why the Ranking Is Not Close

Preeclampsia and gestational hypertension share the same starting point: new hypertension after 20 weeks. What separates them is protein in the urine or signs of organ involvement. The dip, the headache and the hand swelling all point toward preeclampsia, and none points away from it. The ranking therefore rests on the confirmatory test, not on general frequency. In a different patient, with the same pressure at 34 weeks and a clear dip and no symptoms, gestational hypertension would rank first, and the plan would still include the same laboratory tests, because about a quarter of those patients progress.

What the Fundal Height Adds

A fundal height 2 cm behind at 34 weeks would be noted and rechecked in a low-risk pregnancy. In a patient with new preeclampsia, it is a reason for an ultrasound now, because the placental circulation suffers in preeclampsia and the fetus may grow more slowly as a result. The ultrasound showed an estimated fetal weight at the 18th percentile with normal amniotic fluid, which supports continued outpatient monitoring rather than earlier delivery. A repeat growth scan is planned in two to three weeks, alongside the twice-weekly fetal heart rate tracings.

The Role of the Nurse Practitioner

At this practicum site, the family nurse practitioner provides prenatal care for low-risk pregnancies and refers to obstetrics when a pregnancy becomes high risk. J.T.'s diagnosis moved care to the obstetric team. The nurse practitioner's role from here is to coordinate: make sure J.T. understands the plan, has a working home blood pressure monitor and knows the warning signs, and to resume primary care after birth, including the postpartum blood pressure checks.

After Birth

The nurse practitioner will see J.T. for the postpartum visit and continue primary care.

Blood pressure can rise in the first week after delivery. A pressure check within 72 hours of discharge and again at 7 to 10 days is planned. Preeclampsia also raises J.T.'s long-term risk of cardiovascular disease, so the postpartum plan includes a reminder for annual blood pressure checks.

References

American College of Obstetricians and Gynecologists. (2020). Gestational hypertension and preeclampsia: ACOG practice bulletin, number 222. Obstetrics & Gynecology, 135(6), e237-e260. https://doi.org/10.1097/AOG.0000000000003891

US Preventive Services Task Force. (2021). Aspirin use to prevent preeclampsia and related morbidity and mortality: US Preventive Services Task Force recommendation statement. JAMA, 326(12), 1186-1191. https://doi.org/10.1001/jama.2021.14781

US Preventive Services Task Force. (2023). Screening for hypertensive disorders of pregnancy: US Preventive Services Task Force final recommendation statement. JAMA, 330(11), 1074-1082. https://doi.org/10.1001/jama.2023.16991