The nurse is continuing to care for the client. 

Exhibits

The nurse is reviewing the assessment findings.

For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Rationale:

A. Expresses pain freely and loudly: Many Chinese American clients may view overt pain expression as a loss of control or dignity. Cultural norms often encourage stoicism, and clients may underreport pain unless directly asked in a sensitive and respectful manner.

B. Prefers foods that maintain a balance of hot and cold within the body: Traditional Chinese medicine emphasizes balance, particularly of hot and cold elements, especially during the postpartum period. Clients may prefer warm foods and drinks to restore balance and promote healing after childbirth.

C. Prefers to make direct eye contact with health care personnel: In Chinese cultural contexts, direct eye contact can be considered disrespectful or confrontational, especially toward authority figures. Avoiding eye contact may be a sign of respect rather than disinterest.

D. Tends to be very expressive with gestures and body language: Chinese American clients may communicate in a more reserved and controlled manner, often minimizing the use of expressive gestures. Nonverbal communication may be subtle, requiring attentive observation.

Rationale for Correct Choices:

• Seizures: The client presents with severe preeclampsia, indicated by BP >160/110 mm Hg, 3+ proteinuria, hyperreflexia (patellar reflex 4+), and persistent headache. These are strong predictors of progression to eclampsia, which is marked by seizures.
• Placental Abruption: Severe hypertension increases the risk of placental abruption due to vascular compromise in the uteroplacental circulation. Decreased fetal movement may be an early warning sign of impaired placental perfusion or separation.

Rationale for Incorrect Choices:

• Cervical Insufficiency: This is a painless cervical dilation often leading to second-trimester loss, unrelated to hypertension or proteinuria. The client is in the third trimester with no signs of cervical changes.
• Hypoglycemia: The client has no history of diabetes, glucose intolerance, or related symptoms. Her urine glucose was only trace, and no medications suggest insulin use.
• Heart Failure: No signs of pulmonary congestion, dyspnea, or elevated heart rate are present. Oxygen saturation is normal, and breath sounds are not mentioned as abnormal, making CHF unlikely at this stage.