A home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the physician?

1. A

   Urinary output has increased

2. B

   Dependent edema has resolved

3. C

   Blood pressure reading is at the prenatal baseline

4. D

   The clients complains of a headache and blurred Vision

Appeared in: RAK Nursing Officer - 2019

Explanation

• Complaints of headache and blurred vision are classic signs of central nervous system (CNS) involvement in preeclampsia.
• These symptoms are caused by cerebral vasospasm and edema, which increase intracranial pressure and irritate the brain.
• They are considered 'ominous' or 'alarm' symptoms because they signal a progression to severe preeclampsia and are often precursors to eclamptic seizures.
• This finding represents a medical emergency requiring immediate physician notification and likely hospitalization for management to prevent maternal and fetal complications.

Why Other Options Were Wrong

• Option A: Increased urinary output is a sign of improving renal perfusion and function, indicating that the preeclampsia is getting better, not worse.
• Option B: Resolution of dependent edema (swelling in the feet and ankles) is a positive sign, suggesting fluid is being properly mobilized and excreted.
• Option C: A blood pressure reading at the client's prenatal baseline indicates that her condition is stable or improving.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Assessment and recognition of signs indicating the progression from mild to severe preeclampsia to guide bedside assessment, documentation, and the next nursing action.
• The home care nurse plays a vital role in educating the client and her family about the warning signs of worsening preeclampsia (headache, vision changes, abdominal pain). This education empowers the client to report symptoms promptly.
• Immediate reporting of these symptoms is crucial as it allows for timely intervention, such as administration of magnesium sulfate for seizure prophylaxis and planning for delivery, which is the only definitive cure.
• Failure to recognize and act on these signs can lead to life-threatening complications for both mother and baby, including eclampsia, HELLP syndrome, placental abruption, and fetal distress or demise.

How to Approach the Question

• First, identify the core of the question: you need to find a sign that indicates a patient's 'mild preeclampsia' is getting 'worse'.
• Review the patient's diagnosis. Mild preeclampsia is characterized by hypertension and proteinuria without signs of severe end-organ damage.
• Evaluate each option to determine if it represents an improvement or a deterioration.
• Option A (increased urine output) and Option B (resolved edema) are signs of improvement in fluid balance and kidney function.
• Option C (BP at baseline) is a sign of stabilization.
• Option D (headache and blurred vision) points to new-onset neurological symptoms. Recall that CNS disturbances are a hallmark of severe preeclampsia.

Concept Tested & Keywords

• Concept Tested: Assessment and recognition of signs indicating the progression from mild to severe preeclampsia.
• Stem keywords: pregnant client, mild preeclampsia, home care nurse, assessment finding, worsening, notify the physician
• Lead-in keywords: indicates a worsening
• Clinical cues: A diagnosis of mild preeclampsia signals the need for close monitoring for progression to severe disease.
• Clinical cues: The setting is home care, which places a high responsibility on the nurse to identify critical changes and act quickly.

Question ID

QesIDYqFDdr_t3ra62kTmP

Copy ID

Reference Book

E6 Obstetrics Williams p. 2-9

E6 Midwifery Obstetrics and Gynecology Nursing Sandeep Kaur p. 34-42