A nurse is assessing four clients in a prenatal clinic.
Which of the following clients should the nurse recommend that the provider see first?

Choice A rationale: Blood pressure readings below 160/110 mm Hg overnight indicate some level of blood pressure control, which is a positive sign in hypertensive pregnancy conditions. The goal is to maintain pressures below this threshold to reduce risk of end-organ damage. Stable or lower pressures reduce cerebral and placental ischemia risk. Therefore, resting well with controlled BP suggests no immediate worsening, indicating progression is stable at this point.

Choice B rationale: A decrease in headache intensity temporarily is a favorable clinical sign. Headache in preeclampsia is caused by cerebral edema and vasospasm, so improvement indicates less neurological irritation or pressure. However, this is a transient improvement and must be interpreted cautiously, but the reduction alone does not indicate a worsening condition, so it is not a marker of poor progression.

Choice C rationale: An increased headache intensity rating to 7/10 signals significant neurological involvement and increased cerebral irritation, typical of worsening preeclampsia or impending eclampsia. Severe headaches in pregnancy with hypertension indicate cerebral vasospasm or edema, which may lead to seizures if untreated. This is a critical sign requiring urgent intervention to prevent maternal and fetal morbidity.

Choice D rationale: Persistent visual disturbances such as seeing spots or flashes are neurological symptoms indicating retinal or cerebral involvement due to vasospasm, ischemia, or edema. These symptoms are common in severe preeclampsia and herald worsening disease. Visual symptoms result from endothelial dysfunction affecting cerebral and retinal vessels, requiring immediate evaluation to prevent progression to eclampsia.

Choice E rationale: Epigastric discomfort reflects stretching or ischemia of the liver capsule from hepatic involvement in severe preeclampsia or HELLP syndrome. This pain typically presents as right upper quadrant or epigastric pain due to hepatocellular injury or microvascular thrombosis. It is a warning sign of multisystem involvement and potential progression to life-threatening complications such as hepatic rupture.

Choice F rationale: Hyperactive deep tendon reflexes (3+ to 4+) and positive clonus are clinical signs of central nervous system irritability caused by increased excitability of motor neurons. This occurs due to cerebral vasospasm and ischemia in severe preeclampsia and predicts risk for seizures (eclampsia). These neurological signs are crucial in assessing disease severity and necessitate urgent management.

Choice G rationale: Urine output between 25 and 55 mL/hr approaches the lower limit of normal (normal ≥30 mL/hr). Reduced urine output in preeclampsia indicates renal hypoperfusion or injury due to endothelial dysfunction and vasospasm, which can progress to acute kidney injury. Monitoring urine output is essential as oliguria signals worsening renal compromise, increasing maternal and fetal risk.

Choice A rationale

Acrocyanosis, characterized by bluish discoloration of the hands and feet, is a common and usually benign finding in newborns, especially shortly after birth due to immature peripheral circulation. It does not typically indicate neonatal abstinence syndrome, which is a neurological and systemic hyperexcitability response to opioid withdrawal.

Choice B rationale

Hypotonia, or decreased muscle tone, is generally a sign of central nervous system depression or neuromuscular disorder. In contrast, newborns with neonatal abstinence syndrome typically exhibit hypertonia, characterized by increased muscle tone, tremors, and hyperreflexia, due to the overstimulation of the central nervous system following cessation of maternal opioid exposure.

Choice C rationale

An exaggerated Moro reflex, characterized by an overly robust and prolonged startle response, is a common manifestation of central nervous system irritability seen in newborns experiencing neonatal abstinence syndrome. This hyperreflexia is a direct result of the withdrawal symptoms, indicating an overactive nervous system in response to the absence of the previously supplied opioid.

Choice D rationale

Tachypnea, or rapid breathing, is a frequent finding in newborns with neonatal abstinence syndrome. This symptom is often attributed to central nervous system irritability and increased metabolic demand associated with withdrawal, leading to respiratory distress. The respiratory rate often exceeds the normal range of 30-60 breaths per minute.

Choice E rationale

A shrill-pitched cry, often described as inconsolable or high-pitched, is a classic and distinctive symptom of neonatal abstinence syndrome. This abnormal cry pattern is indicative of central nervous system irritation and dysregulation, reflecting the newborn's discomfort and hyperirritability stemming from opioid withdrawal. This cry often differs from a typical hunger or discomfort cry.