A pregnant client at 34 weeks gestation reports a severe hea… | MyMerci
Lifestyle ChoicesHPM
Question
A pregnant client at 34 weeks gestation reports a severe headache and blurred vision. The blood pressure is 164/108 mm Hg. What is the nurse's priority action?
1Notify the provider and prepare for further evaluation of preeclampsia.✓ Correct answer
2Reassure the client that headaches are expected late in pregnancy.
3Encourage the client to walk for 20 minutes and recheck blood pressure.
4Offer a low-sodium snack and discharge the client home.
Explanation
Severe hypertension with headache and visual symptoms suggests preeclampsia with severe features. The nurse should notify the provider and prepare for urgent evaluation and management. Reassurance, exercise, or discharge can delay treatment and increase maternal and fetal risk.
In-depth explanation
Clinical Judgment In pregnancy, severe blood pressure plus neurologic symptoms is a danger pattern.
Memory Tip Headache, vision, high BP: think preeclampsia.
Clinical scenario
Clinical Practice Guide Preeclampsia warning signs include severe headache, visual changes, severe hypertension, abdominal pain, and swelling with pregnancy risk context.
Caution Do not treat severe symptoms as routine pregnancy discomfort.
Key concepts
Preeclampsia — A pregnancy disorder involving hypertension and potential organ dysfunction.
Severe Features — Findings such as severe blood pressure, neurologic symptoms, or organ injury.
Blurred Vision — A visual symptom that can signal neurologic involvement in preeclampsia.