A nurse is caring for a client who is 42 weeks of gestation.

Exhibits

Based on the updated assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse’s planned actions are anticipated, nonessential, or contraindicated.

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Choice A rationale: A headache that lasts for 2 days and is not relieved by Tylenol is a concerning symptom in a pregnant client. This could be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious — even fatal — complications for both mother and baby. Severe headaches are a common symptom of preeclampsia and should be reported to the healthcare provider immediately.

Choice B rationale: Blurred vision and dizziness are also symptoms of preeclampsia. These symptoms occur as a result of changes in the blood vessels in the brain due to high blood pressure. The brain relies on a healthy blood supply to function properly, and any disruption to this can lead to symptoms such as blurred vision and dizziness. These symptoms should be reported to the healthcare provider immediately as they may indicate a need for immediate treatment or monitoring.

Choice C rationale: While swelling of the feet is common in pregnancy due to fluid retention and increased blood flow, it is not typically a symptom that needs to be reported to the healthcare provider unless it is accompanied by other symptoms of preeclampsia or other complications. Swelling in the face and hands is more concerning than swelling in the feet.

Choice D rationale: 2+ pitting edema of the lower extremities is a sign of fluid overload in the body, which can be a symptom of preeclampsia. This should be reported to the healthcare provider as it may indicate a need for treatment or closer monitoring.

Choice E rationale: Deep tendon reflexes of 3+ and absent clonus are within normal limits for a pregnant client. Hyperreflexia (reflexes rated as 4+) and the presence of clonus could indicate neurological irritability associated with preeclampsia, but these findings are not present in this client.

Choice F rationale: Fetal heart tones of 150/min are within the normal range of 110-160 beats per minute. This is a reassuring sign and does not need to be reported to the healthcare provider.

Choice G rationale: A blood pressure of 180/99 mm Hg is significantly elevated and is a hallmark sign of preeclampsia. This should be reported to the healthcare provider immediately as it indicates severe preeclampsia, which requires immediate treatment to prevent complications such as eclampsia, placental abruption, and organ damage.