Which interventions should be immediately initiated when caring for a patient at 32 weeks' gestation who presents with a moderate amount of painless bright red vaginal bleeding?

Rationale for Correct Condition

Preeclampsia with severe features is characterized by hypertension (≥160/110 mm Hg), proteinuria, and evidence of end-organ dysfunction. The client’s elevated BP, proteinuria, headache, hyperreflexia with clonus, and abnormal liver function tests indicate severe preeclampsia rather than gestational hypertension or HELLP syndrome. The absence of seizures rules out eclampsia.

Rationale for Correct Actions

Magnesium sulfate prevents seizures by blocking neuronal excitability and reducing cerebral vasospasm, acting as a neuroprotective agent. Labetalol lowers BP by reducing vascular resistance, preventing stroke and organ damage while maintaining uteroplacental perfusion.

Rationale for Correct Parameters

Blood pressure directly reflects disease progression and response to antihypertensives. Severe hypertension increases the risk of cerebral hemorrhage and placental abruption. Deep tendon reflexes indicate neurological involvement. Hyperreflexia signals worsening preeclampsia, while diminished reflexes may indicate magnesium toxicity.

Rationale for Incorrect Conditions

Gestational hypertension lacks proteinuria and systemic involvement. HELLP syndrome involves hemolysis, low platelets, and severe liver dysfunction, which this client does not meet fully. Eclampsia requires the presence of seizures, which are absent.

Rationale for Incorrect Actions

IV antibiotics are not indicated without confirmed infection. Cesarean delivery is considered for fetal distress but is not first-line in controlled preeclampsia. Betamethasone is used for fetal lung maturity before 34 weeks, making it unnecessary at 37 weeks.

Rationale for Incorrect Parameters

Platelet count is relevant for HELLP syndrome but does not guide preeclampsia management alone. Fetal heart rate variability monitors fetal status but does not directly assess preeclampsia severity. Serum bilirubin is not a primary indicator of preeclampsia progression.

Choice A rationale

A urinalysis with a specific gravity within the expected range (typically 1.005 to 1.030) suggests that the client's kidneys are able to concentrate urine appropriately. This finding does not directly indicate a urinary tract infection or vaginal infection. It reflects the hydration status and renal function.

Choice B rationale

The presence of ketones in the urine typically indicates fat metabolism due to insufficient carbohydrate intake, which is not a direct indicator of a urinary tract infection or vaginal infection. However, the presence of bacteria in the urinalysis strongly suggests a urinary tract infection, a potential cause of the client's symptoms.

Choice C rationale

Pain, particularly pelvic or lower abdominal pain, along with foul-smelling vaginal discharge are classic signs and symptoms of a vaginal infection, such as bacterial vaginosis or trichomoniasis. These symptoms are indicative of an inflammatory or infectious process in the reproductive tract.

Choice D rationale

Denying unprotected sexual activity reduces the likelihood of sexually transmitted infections as the cause of symptoms like vaginal discharge. However, other types of vaginal infections (e.g., bacterial vaginosis, yeast infection) or urinary tract infections can occur regardless of sexual activity.

Choice E rationale

A cloudy appearance in the urinalysis suggests the presence of particulate matter, such as bacteria, white blood cells, or epithelial cells, which can indicate an infection in the urinary tract. While the pH is not provided, a pH outside the normal range (typically 4.6 to 8.0) can also support the suspicion of a urinary tract infection.