Severe Preeclampsia
A 29-year-old first-time mother at 36 weeks gestation comes to the obstetric triage unit reporting a persistent headache, blurred vision and upper abdominal pain.
Recognize cues
Vital signs: BP 168/112 repeated after 15 minutes at 172/110, HR 92, RR 18. Deep tendon reflexes are 4+ with clonus, urine protein is 3+, platelets are 118,000. Fetal heart rate is 140 with moderate variability.
Which finding requires the most immediate follow-up?
Take action
The provider orders IV magnesium sulfate, IV labetalol, continuous fetal monitoring, an indwelling catheter for hourly output, and preparation for delivery.
Which two actions should the nurse take first?
Evaluate outcomes
Two hours later the client reports the headache and visual changes have resolved. BP 138/86, reflexes 2+ without clonus, urine output 45 mL per hour, respirations 16, fetal heart rate reassuring.
Which finding best indicates the treatment is working?
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