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?
1Offer a low-sodium snack and discharge the client home.
2Reassure the client that headaches are expected late in pregnancy.
3Notify the provider and prepare for further evaluation of preeclampsia.✓ Correct answer
4Encourage the client to walk for 20 minutes and recheck blood pressure.
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.
Clinical Judgment In pregnancy, severe blood pressure plus neurologic symptoms is a danger pattern.
Memory Tip Headache, vision, high BP: think preeclampsia.
Clinical Practice GuidePreeclampsia warning signs include severe headache, visual changes, severe hypertension, abdominal pain, and swelling with pregnancy risk context.
CautionDo not treat severe symptoms as routine pregnancy discomfort.
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.