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 antihypertensive medication as ordered
2Place the client in a quiet, dimly lit room✓ 정답
3Prepare for immediate cesarean delivery
4Insert an indwelling urinary catheter
해설
The priority intervention is placing the client in a quiet, dimly lit room to reduce stimuli and prevent eclamptic seizures. Other interventions like antihypertensive administration or cesarean preparation are important but secondary to immediate seizure prevention.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a patient with severe preeclampsia. The core pathophysiology involves severe vasospasm and endothelial damage, leading to hypertension and proteinuria. The most life-threatening complication is progression to eclampsia (seizures), which can cause maternal and fetal hypoxia, placental abruption, and death. Therefore, the immediate nursing priority is seizure prophylaxis.
Answer Rationale: Key Point! The first action is to reduce environmental stimuli to prevent a seizure. Placing the client in a quiet, dimly lit room is a non-pharmacologic, immediate intervention that directly addresses the primary risk. This aligns with the nursing process: before implementing medical orders (like medications) or preparing for procedures, the nurse must first create a safe environment to prevent the most acute complication.
Distractor Analysis:
Watch out for confusion! Option ① (Administer antihypertensive medication) is a critical intervention to manage hypertension and prevent stroke, but it is not the first action. Medication administration follows assessment and environmental management. The nurse must ensure the patient is in a safe position and setting before giving any medication.
Option ③ (Prepare for immediate cesarean delivery) is incorrect. While delivery is the definitive cure for preeclampsia, it is not the first nursing intervention upon admission. Stabilizing the mother and preventing seizures takes precedence. The decision for delivery timing is made by the physician after maternal stabilization.
Option ④ (Insert an indwelling urinary catheter) is important for strict intake and output (I&O) monitoring in severe preeclampsia, but it is not the priority over seizure prevention. It is a secondary intervention that can be performed after initial stabilization.
Related Concepts: The management of severe preeclampsia follows the "B" priorities: Bed rest (left lateral position), Blood pressure control, and prevention of Birth (seizures) with magnesium sulfate. The ultimate goal is to protect both mother and fetus until safe delivery can be achieved.
Concept Summary
Term
Definition & Significance
Preeclampsia
Hypertensive disorder of pregnancy after 20 weeks with proteinuria. Pathophysiology involves vasospasm and endothelial dysfunction.
Severe Features
Defined by BP ≥160/110 mmHg, severe proteinuria (≥5g/24hr or 3+ on dipstick), symptoms (headache, visual changes, epigastric pain), thrombocytopenia, impaired liver function, pulmonary edema, or fetal growth restriction.
Eclampsia
The onset of seizures in a patient with preeclampsia, not attributable to other causes. It is a medical emergency.
Magnesium Sulfate
Drug of choice for seizure prophylaxis and treatment in preeclampsia/eclampsia. It is a central nervous system depressant, not an antihypertensive.
Side-by-Side Comparison!
Intervention
Priority Rationale
Timing
Quiet, Dark Room
Immediate seizure prophylaxis by reducing sensory stimuli (light, noise).
First Action
Administer MgSO4 / Antihypertensives
Pharmacologic seizure prevention and BP control to prevent stroke.
Secondary (after initial safety measures)
Prepare for Delivery
Definitive treatment for preeclampsia. Decision based on maternal/fetal status and gestation.
After maternal stabilization
Strict I&O / Foley Catheter
Monitor for fluid overload (pulmonary edema risk) and renal function.
Important but not the immediate life-saving priority
Anatomy, Physiology & Pharmacology Points
The primary pathophysiological defect in preeclampsia is generalized vasospasm. This reduces organ perfusion (brain, kidneys, liver, placenta) and increases peripheral vascular resistance, causing hypertension. Reduced placental perfusion can lead to fetal growth restriction. Magnesium sulfate works by blocking calcium channels at the neuromuscular junction, depressing the central nervous system to prevent seizure activity. Common antihypertensives used include labetalol (alpha and beta-blocker) and hydralazine (direct vasodilator).
Memory TipsHELLP Syndrome: A severe form of preeclampsia.
Hemolysis
Elevated Liver enzymes
Low Platelets
Think "B" for Bed, BP, and Birth (seizure) prevention.
For priority: "Seizure First, Then Pressure" – Prevent the convulsion before aggressively treating the number.
High-Frequency NCLEX Topics
Preeclampsia is a High Yield topic. NCLEX loves to test:
1. Priority Setting: Seizure prevention (environment, MgSO4) over other interventions.
2. Assessment of Severe Features: Recognizing symptoms like headache, visual changes, and epigastric pain.
3. MgSO4 Administration & Toxicity: Knowing normal therapeutic levels (4-8 mg/dL), signs of toxicity (loss of deep tendon reflexes (DTRs) at >10 mg/dL, respiratory depression/cardiac arrest at >15 mg/dL), and that calcium gluconate is the antidote.
Watch Out for Question Variations!
* Instead of asking for the first intervention, it might ask: "Which client finding requires immediate notification of the provider?" (Answer: Signs of impending eclampsia like severe headache or hyperreflexia with clonus).
* It could shift to postpartum: "A postpartum client with preeclampsia is receiving MgSO4. Which finding indicates toxicity?" (Answer: Respiratory rate < 12/min or absent DTRs).
* It might combine with fetal monitoring: "What is the priority action if late decelerations are noted in a client with severe preeclampsia?" (Answer: Turn client to left lateral position to improve placental perfusion, then administer O2, then notify provider).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse admitting Ms. Johnson, a 32-year-old G1P0 at 32 weeks, to the labor and delivery unit. She reports a worsening headache and "seeing spots." Her BP is 160/110, and a urine dip shows 3+ protein. She is anxious.
Nursing Intervention Strategy:
1Immediate Action (Assessment & Safety)Introduce yourself calmly. Immediately assist her to a private, quiet room with dimmed lights. Place a "Quiet Please" sign on the door. Have seizure precautions at bedside (padded side rails, oral airway, suction equipment). Position her in left lateral recumbent position to optimize uteroplacental blood flow and renal perfusion.
2Comprehensive AssessmentPerform a focused neurologic assessment: check for hyperreflexia, clonus, visual disturbances, and level of consciousness. Assess for epigastric/RUQ pain (sign of liver involvement). Monitor fetal heart rate (FHR) and contraction patterns continuously.
3Implementation of OrdersAfter the environment is secured, you will likely have orders to:
* Initiate MgSO4 IV infusion (loading dose then maintenance) for seizure prophylaxis. Monitor DTRs, respiratory rate, and urine output hourly.
* Administer antihypertensive (e.g., labetalol IV) to gradually lower BP.
* Insert a Foley catheter for strict I&O.
* Obtain labs (CBC, liver enzymes, creatinine, coagulation studies).
4Patient Education & SupportExplain all procedures simply. Reassure her that the team is focused on keeping her and her baby safe. Educate on the purpose of MgSO4 and the importance of reporting any new symptoms immediately.
Patient Safety and Precautions:
* Key Point!MgSO4 Toxicity: Always have calcium gluconate (the antidote) at the bedside. Assess DTRs before each new bag of MgSO4. If DTRs are absent, hold the infusion and notify the provider immediately.
* Fluid Overload Risk: Patients are at high risk for pulmonary edema. Strictly adhere to fluid restrictions (often total IV fluids are limited to 125 mL/hr or less). Monitor for crackles in lungs and increasing shortness of breath.
* Fetal Surveillance: Continuous electronic fetal monitoring (EFM) is mandatory. Be prepared for emergency delivery if there are signs of fetal distress (e.g., repetitive late decelerations, bradycardia) or maternal deterioration.
3Monitoring* Before initiation and hourly: Assess DTRs, respiratory rate (>12/min), and level of consciousness.
* Continuous: Monitor urine output (must be >30 mL/hr). Mg is excreted renally; low output increases toxicity risk.
* Serum Levels: Therapeutic range is 4-8 mg/dL.
4AntidoteCalcium gluconate 1 g IV push over 3 minutes for signs of life-threatening toxicity (respiratory depression, cardiac arrest).
A Word from Your Senior Nurse
"Managing a patient with severe preeclampsia is one of the most critical skills in obstetric nursing. Your role as the first responder is to be the calm in the storm. That quiet, dark room isn't just about comfort—it's a therapeutic intervention to literally protect her brain from seizing. Always remember your ABCs with a twist: Airway/Breathing/Circulation, but also 'Assess for Seizure risk first.' When you see those high BP numbers, it's tempting to jump straight to the medication drawer, but your first move is to create a safe environment. This holistic, patient-safety-first thinking is exactly what the NCLEX tests and what will make you an exceptional nurse at the bedside."
Preeclampsia — A hypertensive disorder specific to pregnancy, occurring after 20 weeks gestation, characterized by new-onset hypertension and proteinuria. It involves systemic vasospasm and endothelial damage.
Eclampsia — The development of seizures in a patient with preeclampsia, not attributable to other cerebral conditions. It is a life-threatening obstetric emergency.
Magnesium Sulfate — A central nervous system depressant and the drug of choice for preventing and treating seizures in preeclampsia and eclampsia. It is not an antihypertensive.
HELLP Syndrome — A severe variant of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets. It represents a multi-organ crisis.
Left Lateral Recumbent Position — The recommended position for pregnant patients, especially those with hypertension. It displaces the uterus off the inferior vena cava and aorta, improving venous return, cardiac output, and placental perfusion.