A pregnant client at 34 weeks has blood pressure 168/112 mm Hg, a severe headache, blurred vision, and right upper quadrant pain. Magnesium sulfate is prescribed. Complete the statement.
Drop-down Cloze
Choose your responses, then check the answer.
Explanation
Blood pressure 168/112 mm Hg with severe headache, visual changes, and right upper quadrant pain indicates preeclampsia with severe features. The nurse institutes seizure precautions, monitors magnesium sulfate therapy, and supports urgent treatment of persistent severe hypertension. Magnesium sulfate prevents eclamptic seizures; it is not an antihypertensive. At 34 weeks, delivery is generally planned after maternal stabilization unless immediate delivery is required sooner.
Correct Answer Recognize preeclampsia with severe features and prepare for seizure precautions, magnesium sulfate monitoring, and urgent severe-hypertension treatment.
Why It Fits A blood pressure of 168/112 mm Hg plus headache, visual symptoms, and right upper quadrant pain shows maternal neurologic and hepatic risk, not normal late-pregnancy discomfort.
Clinical Picture Magnesium sulfate is the seizure shield; antihypertensive therapy addresses the pressure injury. Both are needed because they solve different immediate threats.
Memory Link Severe pressure plus head, vision, or right-upper-quadrant symptoms means stabilize, prevent seizure, treat pressure, and plan delivery.
NCLEX Rule When maternal danger signs appear, choose stabilization and escalation before ambulation, routine teaching, or isolated fluid advice. Continue maternal-fetal assessment while preparing for delivery after stabilization.
Why the Alternatives Fail Braxton Hicks contractions and gestational rhinitis do not explain severe hypertension with neurologic symptoms. Ambulation and routine discharge teaching delay emergency treatment, and fluid restriction alone does not treat the disorder.
Source
1ACOG Practice Bulletin: Gestational Hypertension and Preeclampsia
Clinical Practice GuideSevere-range blood pressure, persistent headache, visual symptoms, and right upper quadrant pain indicate preeclampsia with severe features. Magnesium sulfate prevents seizures but does not replace urgent treatment of severe hypertension.
CautionAt 34 weeks, stabilization and timely delivery planning take priority over routine pregnancy teaching.
Preeclampsia — A hypertensive disorder of pregnancy that may involve neurologic, renal, hepatic, or hematologic complications.
Magnesium Sulfate — A medication used in severe preeclampsia to reduce the risk of seizures.
Seizure Precautions — Safety measures that reduce injury risk if a seizure occurs.