A 22-year-old woman visits the clinic requesting birth control. Her medical history includes dysmenorrhea, irregular menstrual cycles, and menorrhagia. She smokes half a pack of cigarettes daily and reports being sexually active with multiple partners. Which birth control method is most appropriate for this client?

A. Deep tendon reflexes (DTR) – Worsening

On 2/10, the client had hyperreflexia (DTRs 3+) and no clonus. By 2/11, the DTRs had increased to 4+ with positive clonus, indicating neuromuscular hyperexcitability, a hallmark of worsening preeclampsia with severe features. Clonus is a concerning sign that suggests progression toward eclampsia (seizures). This indicates neurological worsening.

B. Creatinine – Worsening

The client's creatinine level increased from 1.4 mg/dL (already elevated) to 2.0 mg/dL, which is indicative of worsening renal function. Normal pregnancy should not cause a creatinine rise above 1.1 mg/dL, so this elevation suggests renal impairment due to severe preeclampsia. The worsening creatinine level indicates deteriorating kidney function, possibly due to reduced renal perfusion.

C. Client denies pain – Unrelated

The absence of pain is not directly related to the client’s condition worsening or improving. While pain can be a symptom of severe preeclampsia (such as epigastric pain from liver involvement), the client currently has an epidural, which can explain the lack of pain perception. The denial of pain does not indicate improvement in the disease process but rather effective pain management.

D. Vaginal exam – Improvement

The vaginal exam findings indicate progress in labor. On 2/10, the client was not noted to be in active labor, but by 2/11, she was 7 cm dilated, 80% effaced, and at 0 station, with contractions increasing in frequency and intensity. This progression suggests that labor is advancing appropriately.

E. Blood pressure – Worsening

The client’s blood pressure was severely elevated on 2/10 (168/100 mmHg) and remained high on 2/11 (152/86 mmHg). While slightly lower, the diastolic remains elevated, and systolic pressures are still high. Given the worsening DTRs, renal function decline, and elevated liver enzymes, the blood pressure changes are not a sign of improvement but rather persistent hypertension despite possible interventions.

F. Decreased sensation in legs – Unrelated

The client received an epidural for pain relief, which normally causes decreased sensation in the lower extremities. This finding is not related to worsening preeclampsia or labor progression but is an expected effect of the epidural anesthesia. The client’s ability to slightly move her legs confirms that the block is working properly.

Priority concerns:

Liver function tests: The client has elevated ALT (75 U/L), AST (78 U/L), alkaline phosphatase (184 U/L), and LDH (250 U/L), which are consistent with liver involvement in preeclampsia with severe features. This suggests hepatic dysfunction and possible progression to HELLP syndrome.

Blood pressure: The client’s BP is 168/100 mmHg, which meets the criteria for severe preeclampsia (≥160/110 mmHg). Uncontrolled hypertension increases the risk of stroke, placental abruption, and progression to eclampsia.

Headache: The persistent headache could indicate severe preeclampsia with neurological involvement due to cerebral vasospasm and increased risk of stroke or seizure. A headache that does not resolve with usual measures is a warning sign, and magnesium sulfate should be considered for seizure prophylaxis.

Not a Priority Concern

Heartburn is a common symptom in pregnancy due to gastric reflux and increased progesterone levels, which relax the lower esophageal sphincter. While it can be uncomfortable, it is not immediately life-threatening.

Gestational age: The client is at 37 weeks’ gestation, which is considered early term but not preterm. While gestational age is important for delivery planning, it is not the most immediate concern compared to the client’s hypertensive crisis.

Cardiac assessment: The apical pulse is 77 bpm, regular, and lungs are clear, indicating that there is no immediate cardiac or respiratory compromise.