A pregnant client at 32 weeks gestation is admitted with severe preeclampsia. Her blood pressure is 160/110 mmHg, and she has 3+ proteinuria. Which nursing intervention should be implemented first?
1Administer prescribed antihypertensive medication to lower blood pressure
2Insert an indwelling urinary catheter for accurate output monitoring
3Prepare the client for an immediate cesarean delivery procedure
4Place the client in a quiet, dimly lit room and initiate seizure precautions✓ 정답
해설
The priority nursing intervention for a client with severe preeclampsia is to create a safe environment and prevent seizures (eclampsia), which is a life-threatening complication.
Severe preeclampsia is a serious pregnancy complication that occurs after 20 weeks of gestation, characterized by high blood pressure (≥160/110 mmHg) and severe proteinuria (≥3+). Pathophysiologically, widespread vasospasm, endothelial dysfunction, and increased vascular permeability can lead to reduced organ perfusion and multi-organ dysfunction.
The most important immediate concern in severe preeclampsia is the risk of progression to eclampsia (seizures). Eclampsia involves seizure activity and can be fatal for both the mother and fetus. Seizures can occur suddenly and without warning, making prevention the top priority.
Environmental modification is an essential first-line intervention that can be implemented immediately without waiting for a physician's order. Placing the patient in a quiet, darkened room reduces sensory stimuli that can trigger seizures. Seizure precautions include having suction equipment, oxygen, and emergency medications readily available, padding the bed rails, and keeping the bed in the lowest position.
Administering antihypertensive medications, inserting an indwelling catheter, and preparing for delivery are also important components of managing severe preeclampsia, but they are secondary to immediate seizure prevention measures. Nursing priorities follow the ABC (airway, breathing, circulation) principle, and seizure prevention is critical for maintaining airway patency and preventing maternal and fetal risks.
Correct Answer: 4. Place the client in a quiet, dimly lit room and initiate seizure precautions
The priority nursing intervention for a client with severe preeclampsia is to prevent the progression to eclampsia, which is defined by the onset of generalized seizures. The pathophysiology of severe preeclampsia involves widespread endothelial dysfunction and cerebral hyperexcitability, which significantly lowers the seizure threshold. Placing the client in a quiet, dimly lit environment is a critical non-pharmacologic intervention that directly reduces central nervous system (CNS) stimulation from external sensory input such as bright lights and noise. Initiating seizure precautions—including padding the side rails, ensuring suction equipment and oxygen are functional and at the bedside, and keeping the bed in the lowest position—is essential to protect the client from injury should a seizure occur. This safety-focused intervention is foundational and must be established immediately upon admission to create a controlled environment before other treatments are administered.
Analysis of Incorrect Options
Option 1: Administer prescribed antihypertensive medication to lower blood pressure. While blood pressure control is a critical component of managing severe preeclampsia to prevent maternal end-organ damage such as stroke, it is not the very first action upon admission. A blood pressure of 160/110 mmHg requires treatment, but the immediate environmental and safety controls take precedence. Furthermore, the cornerstone prophylactic therapy for seizure prevention in this context is magnesium sulfate, not an antihypertensive. The review by Xia et al. confirms that magnesium sulfate is now a cornerstone therapy for these disorders, working through distinct mechanisms to stabilize the CNS and prevent convulsions [1]. The administration of antihypertensives is a subsequent, though urgent, intervention.
Option 2: Insert an indwelling urinary catheter for accurate output monitoring. Monitoring urinary output is a vital assessment for evaluating renal function and fluid balance, especially with 3+ proteinuria indicating significant renal involvement. However, this is an invasive procedure that is not the highest priority upon immediate admission. Accurate intake and output monitoring is a standard component of ongoing care for severe preeclampsia, but it does not address the most imminent threat: the risk of a sudden eclamptic seizure. The initial priority is to stabilize the client’s CNS environment.
Option 3: Prepare the client for an immediate cesarean delivery procedure. Delivery is the only definitive cure for preeclampsia, but at 32 weeks gestation, the immediate goal is typically to stabilize the maternal condition to allow for fetal lung maturity through the administration of corticosteroids, unless there are severe features that necessitate immediate delivery regardless of gestational age. An immediate cesarean section upon admission is not the first-line intervention without first stabilizing the client and initiating seizure prophylaxis. The clinical approach involves a careful balance of maternal and fetal well-being, with the initial focus on preventing maternal seizures, a leading direct cause of maternal death and morbidity worldwide .
Clinical Reasoning and Evidence
The clinical priority framework for this scenario is safety and prevention of the most life-threatening complication: eclamptic seizures. The qualitative study on magnesium sulfate provision highlights that preeclampsia and eclampsia are among the leading direct causes of maternal death, and preventing convulsions is the primary therapeutic goal . The initial nursing actions are therefore structured around this goal. Creating a low-stimulus environment and setting up seizure precautions are independent nursing actions that can be implemented immediately and have a direct impact on preventing a seizure. This is followed by the administration of magnesium sulfate, the pharmacologic cornerstone for seizure prophylaxis, which acts centrally to depress the CNS and at the neuromuscular junction to reduce hyperexcitability [1]. The pharmacokinetic and pharmacodynamic properties of magnesium sulfate require careful monitoring for toxicity, which is why a safe environment must be established first, before the infusion is started and other assessments like urinary output monitoring become critical for evaluating magnesium clearance and renal function.
References (research sources)
[1]
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 Guide
Priority Nursing Action: Upon admission for severe preeclampsia, immediately place the client in a quiet, dimly lit room and initiate full seizure precautions. This non-pharmacologic intervention reduces CNS stimulation and protects against injury from potential eclamptic seizures.
Environmental Control: Minimize all external stimuli. Close curtains, dim lights, cluster nursing care, and restrict visitors to create a low-stimulus environment.
Seizure Precautions Setup: Pad the side rails of the bed, keep the bed in the lowest position, and ensure emergency equipment (oxygen, suction, airway) is connected and functional at the bedside.
Maternal Monitoring: Assess deep tendon reflexes, level of consciousness, and for signs of cerebral irritability such as severe headache or visual disturbances hourly.
Pharmacologic Management: Administer prescribed magnesium sulfate for seizure prophylaxis, monitoring for toxicity (respiratory depression, loss of patellar reflexes, decreased urine output). Antihypertensive therapy is initiated as ordered after safety measures are in place.
Fetal Surveillance: Initiate continuous electronic fetal monitoring to assess fetal well-being and uterine activity, as severe preeclampsia can compromise placental perfusion.
NCLEX-RN Clinical Judgment: Safety and risk reduction (seizure prevention) take precedence over pharmacologic interventions in the initial management of severe preeclampsia.
Severe Preeclampsia — A pregnancy-specific hypertensive disorder after 20 weeks gestation characterized by BP of 160/110 mmHg or higher and proteinuria, with risk of progression to eclampsia.
Eclampsia — The onset of generalized tonic-clonic seizures in a client with preeclampsia, a life-threatening obstetric emergency.
Seizure Precautions — Safety measures including padded side rails, functioning suction and oxygen at the bedside, and a low bed position to prevent injury during a seizure.
Cerebral Hyperexcitability — A state of increased central nervous system irritability in severe preeclampsia that lowers the seizure threshold.