A pregnant woman has a blood pressure of 152/96 mmHg, +2 proteinuria, and a persistent severe headache that does not improve. What is the most appropriate nursing action?

1. A

   Reassess the blood pressure after 15 minutes

2. B

   Perform a non-stress test (NST)

3. C

   Initiate seizure precautions

4. D

   Administer acetaminophen for headache

Appeared in: AIIMS M.Sc. Nsg Entrance exam-2026

Explanation

• The patient's signs and symptoms (hypertension, proteinuria, severe headache) are indicative of severe preeclampsia.
• A severe headache is an alarming symptom suggesting central nervous system (CNS) irritability, which is a direct precursor to eclamptic seizures.
• The highest priority is maternal safety, which involves protecting the patient from injury in the event of a seizure.
• Initiating seizure precautions is the most appropriate and immediate action to mitigate the risk of harm from convulsions.
• This includes creating a safe environment (e.g., padded side rails, low stimuli) and having emergency equipment (suction, oxygen) readily available.

Why Other Options Were Wrong

• Option A: While blood pressure monitoring is crucial, the patient is already exhibiting severe symptoms that require immediate intervention, not just further assessment. Delaying action to recheck the BP would be unsafe.
• Option B: A non-stress test (NST) assesses fetal well-being. In an acute situation threatening the mother's life, maternal stabilization is the absolute priority. The risk of seizure outweighs the need for immediate fetal testing.
• Option D: The headache is caused by cerebral vasospasm and edema, not a simple inflammatory process. Acetaminophen would be ineffective and would dangerously mask a key sign of a worsening neurological status.

Related Visual

• Visual 1: Infographic - Key components of seizure precautions in a hospital setting. This would visually detail padding side rails, having suction and oxygen at the bedside, and maintaining a low-stimulus environment.
• Visual 2: Comparison Table - Signs and symptoms of mild preeclampsia versus severe preeclampsia versus eclampsia. This would help differentiate the conditions and highlight the significance of symptoms like severe headache and visual disturbances.

Clinical Relevance

• Nursing practice connection: Use the key finding related to Nursing priorities in the management of severe preeclampsia to guide bedside assessment, documentation, and the next nursing action.
• Nurses must be able to rapidly identify the signs of worsening preeclampsia to prevent progression to eclampsia, a life-threatening obstetric emergency.
• Prompt initiation of seizure precautions is a critical patient safety intervention that can prevent traumatic injury, aspiration, and hypoxia during a convulsion.
• What if? If the patient had a BP of 152/96 mmHg and +2 proteinuria but reported only a mild headache that resolved with rest, the most appropriate action would be to notify the physician, continue close monitoring of BP and symptoms, and prepare for potential administration of antihypertensives, rather than immediately initiating full seizure precautions.

How to Approach the Question

• First, analyze the patient's clinical data provided in the stem: BP 152/96 mmHg, +2 proteinuria, and a persistent severe headache.
• Recognize that this combination of findings points to a specific high-risk obstetric condition: severe preeclampsia.
• Identify the most life-threatening potential complication associated with these signs. The severe headache is a major red flag for CNS irritability and impending eclamptic seizures.
• Apply the nursing principle of prioritizing safety. The greatest immediate risk to the patient is injury from a seizure.
• Evaluate the options to determine which one directly addresses this primary safety risk.
• Conclude that initiating seizure precautions is the only option that proactively protects the patient from the most immediate danger.

Concept Tested & Keywords

• Concept Tested: Nursing priorities in the management of severe preeclampsia
• Stem keywords: pregnant woman, blood pressure of 152/96 mmHg, +2 proteinuria, persistent severe headache
• Lead-in keywords: most appropriate nursing action
• Clinical cues: The combination of hypertension, proteinuria, and a severe headache is a classic triad for severe preeclampsia.
• Clinical cues: A persistent severe headache indicates central nervous system involvement and is a warning sign for impending eclampsia (seizures).

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