A nurse is caring for a client at 34 weeks gestation who was admitted with severe preeclampsia. The client's blood pressure is 170/110 mmHg, and she reports severe headache and visual disturbances. Laboratory results show proteinuria 3+ and elevated liver enzymes. Which nursing intervention should be the priority?
2Prepare the client for immediate cesarean delivery
3Implement seizure precautions and maintain a quiet, dimly lit environment✓ 정답
4Insert an indwelling urinary catheter to monitor output
해설
Seizure precautions are the priority to prevent eclampsia, as severe headache and visual disturbances indicate imminent seizure risk. Other interventions (antihypertensives, delivery, catheter) are important but secondary to this immediate threat.
Clinical Presentation and Underlying Pathophysiology
The client at 34 weeks gestation presents with a classic triad of severe preeclampsia: critically elevated blood pressure (170/110 mmHg), cerebral symptoms (severe headache and visual disturbances), and laboratory evidence of end-organ damage (proteinuria 3+, elevated liver enzymes). This clinical picture indicates a state of widespread maternal endothelial dysfunction and vasospasm, which has now progressed to central nervous system (CNS) irritability. The severe headache and visual disturbances are not merely discomfort; they are prodromal signs of cortical irritability and cerebral edema, signaling a high imminent risk for seizure activity, known as eclampsia.
Priority Nursing Intervention: Rationale for Seizure Precautions
The priority intervention is to implement seizure precautions and maintain a quiet, dimly lit environment. In the hierarchy of maternal care for severe preeclampsia, the prevention of eclamptic seizures is paramount because an eclamptic seizure leads to severe maternal hypoxia, trauma, and can precipitate placental abruption, fetal distress, and maternal death. The foundational pharmacologic agent for this prevention is magnesium sulfate. Evidence confirms that magnesium sulfate is the drug of choice for the prevention and treatment of eclampsia, acting as a cornerstone therapy to reduce the risk of severe morbidity and mortality for the woman and her baby [1, 2]. The nursing action of creating a quiet, dimly lit environment directly complements this pharmacologic strategy by minimizing external sensory stimuli (photophobia, phonophobia) that can trigger seizure activity in an already hyper-excitable CNS.
Analysis of Other Options in the Context of Immediate Priority
While the other listed interventions are all necessary components of care, they do not take precedence over immediate seizure prophylaxis.
- Administering prescribed antihypertensive medication (Option 1) is critical to prevent maternal intracranial hemorrhage, but it does not directly address the underlying CNS irritability that leads to eclampsia. Blood pressure control and seizure prevention are parallel, emergent goals, but the primary pharmacologic agent for the latter, magnesium sulfate, must be initiated without delay [2].
- Preparing for immediate cesarean delivery (Option 2) is the definitive treatment for preeclampsia, but delivery is not the immediate priority in an unstable, pre-seizure state. The maternal condition must first be stabilized with magnesium sulfate to prevent intraoperative or immediate postoperative seizures, which would be catastrophic [1].
- Inserting an indwelling urinary catheter (Option 4) is essential for strict intake and output monitoring, especially given the risk of oliguria and the need to monitor for magnesium sulfate toxicity, as the drug is renally excreted. However, this is a secondary intervention that follows the initial stabilization and initiation of seizure precautions and magnesium sulfate therapy [2].
Integrating Pharmacology into Nursing Action
The nursing intervention of "implementing seizure precautions" is inseparable from the preparation for and administration of magnesium sulfate. The therapeutic window of magnesium sulfate is narrow, and its use in practice can be heterogeneous [2]. The nurse’s role extends beyond hanging the intravenous medication; it includes establishing safety measures (padded side rails, oxygen and suction equipment at the bedside) and performing continuous clinical monitoring for therapeutic effect, loss of deep tendon reflexes, respiratory depression, and cardiac function, all of which are components of comprehensive seizure precautions grounded in the drug's pharmacology and mechanisms of action [2].
References (research sources)
[1]
Alternative magnesium sulphate regimens for women with pre-eclampsia and eclampsia.Research articleDiaz V, Long Q, Oladapo OT. (2023) · DOI: 10.1002/14651858.cd007388.pub3
[2]
Magnesium sulfate pharmacology for maternal and critical-care indications: mechanisms, pharmacokinetics, and the therapeutic window.Research articleXia M, Ni Q, Zhu S. (2026) · DOI: 10.3389/fphar.2026.1749828
Clinical Management of Severe Preeclampsia with Impending Eclampsia
This case illustrates the critical nursing priority for a patient at 34 weeks gestation with severe preeclampsia exhibiting prodromal signs of eclampsia.
1. Immediate Priority: Seizure Prophylaxis
Primary Intervention: Initiate and maintain seizure precautions. This includes padding the side rails, ensuring the bed is in the lowest position, and having suction equipment, oxygen, and an oral airway readily available at the bedside.
Environmental Control: Maintain a quiet, dimly lit environment to minimize CNS stimulation, which can trigger seizure activity.
Pharmacologic Management: Administer a loading dose of magnesium sulfate intravenously, typically 4-6 g over 15-20 minutes, followed by a maintenance infusion of 1-2 g/hour as prescribed. This is the drug of choice for preventing the progression to eclampsia.
2. Ongoing Maternal-Fetal Monitoring
Magnesium Sulfate Toxicity Assessment: Monitor hourly for signs of toxicity, including loss of deep tendon reflexes (first sign), respiratory depression (respirations < 12/min), decreased urine output (< 30 mL/hr), and altered level of consciousness. Keep calcium gluconate (the antidote) at the bedside.
Blood Pressure Control: Administer prescribed antihypertensives (e.g., IV labetalol or hydralazine) to lower blood pressure to a safe range (typically 140-150/90-100 mmHg) to prevent maternal stroke, while avoiding precipitous drops that could compromise placental perfusion.
Fetal Surveillance: Initiate continuous electronic fetal monitoring to assess for signs of fetal distress, such as late decelerations or bradycardia, which can result from uteroplacental insufficiency.
3. Preparing for Delivery
Definitive Treatment: Once the patient is stabilized and seizure prophylaxis is established, prepare for delivery. For severe preeclampsia at 34 weeks, this often involves administration of corticosteroids (betamethasone) for fetal lung maturity if time allows, followed by induction of labor or cesarean delivery based on maternal-fetal status and cervical favorability.
Postpartum Care: Seizure precautions and magnesium sulfate therapy must continue for 24 hours postpartum, as the risk of eclampsia remains highest during this period.
Eclampsia — The onset of convulsions or coma in a patient with preeclampsia, a life-threatening obstetric emergency.
Severe Preeclampsia — Preeclampsia with severe features such as BP ≥160/110 mmHg, thrombocytopenia, impaired liver function, severe persistent right upper quadrant pain, progressive renal insufficiency, pulmonary edema, or new-onset cerebral or visual disturbances.
Magnesium Sulfate — The first-line anticonvulsant medication for seizure prophylaxis in severe preeclampsia and for treating eclamptic seizures.
Seizure Precautions — Nursing interventions to protect a patient from injury during a seizure, including padding side rails, ensuring suction equipment and oxygen are at the bedside, and maintaining a quiet, dimly lit environment.