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.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a patient with severe preeclampsia showing signs of impending eclampsia. The core pathophysiology involves severe vasospasm and endothelial damage, leading to hypertension, proteinuria, and end-organ dysfunction (like elevated liver enzymes). Neurological symptoms (severe headache, visual disturbances) signal cerebral edema and irritation, which are precursors to a life-threatening tonic-clonic seizure.
Answer Rationale: Key Point! In the nursing process, safety is paramount. The patient's symptoms (severe headache, visual disturbances) are classic prodromal symptoms of an impending eclamptic seizure. The priority intervention is to prevent injury from a seizure. Therefore, implementing seizure precautions (e.g., padded side rails, maintaining a quiet/dim environment to reduce sensory stimulation, having oxygen and suction ready) is the immediate nursing action. This aligns with the ABC (Airway, Breathing, Circulation) priority framework, as a seizure can compromise the airway and oxygenation for both mother and fetus.
Distractor Analysis:
Watch out for confusion! While administering antihypertensive medication (Option 1) is crucial for managing severe hypertension, it is not the immediate priority when neurological symptoms indicating imminent seizure are present. The medication will take time to work, whereas seizure prevention must be initiated instantly.
Option 2 (Prepare for cesarean delivery) is a definitive treatment for severe preeclampsia but is a medical decision. The nurse's priority is to stabilize the patient and prevent complications (seizure) before any procedure. Delivery may be imminent, but patient safety from seizure comes first.
Option 4 (Insert urinary catheter) is important for strict Intake and Output (I&O) monitoring and assessing renal function, but it is a secondary intervention. It does not address the immediate, life-threatening risk of seizure.
Related Concepts: The progression from preeclampsia to eclampsia is a critical emergency. Management focuses on Magnesium sulfate administration (for seizure prophylaxis and treatment), blood pressure control, and often expedited delivery. Understanding the "HELLP syndrome" (Hemolysis, Elevated Liver enzymes, Low Platelets) is also vital, as suggested by the elevated liver enzymes in this scenario.
Concept Summary
Term
Definition & Significance
Preeclampsia
Hypertension (≥140/90 mmHg) with proteinuria after 20 weeks gestation.
Severe Preeclampsia
BP ≥160/110 mmHg, severe proteinuria, symptoms (headache, visual changes, epigastric pain).
Eclampsia
The occurrence of tonic-clonic seizures in a preeclamptic patient, a medical emergency.
Priority: Assess for HELLP, monitor liver enzymes & platelets.
Hyperreflexia (+3/+4)
CNS irritability.
Monitor closely; precedes clonus and seizure.
Anatomy, Physiology & Pharmacology PointsPathophysiology: Placental release of anti-angiogenic factors → widespread maternal endothelial dysfunction → vasoconstriction → hypertension, reduced organ perfusion (kidneys: proteinuria; brain: edema/seizure; liver: inflammation/HELLP).
Drug of Choice: Magnesium sulfate acts on the NMJ (N-methyl-D-aspartate receptors) to reduce neuronal excitability and prevent seizures. Key Point! Monitor for toxicity: loss of deep tendon reflexes (DTRs) is the first sign, followed by respiratory depression and cardiac arrest. Antidote is Calcium gluconate.
Memory TipsAcronym for Severe Features: "HEadache, Epigastric pain, Low platelets, Liver enzymes up, Pulmonary edema" (HELLP plus neuro symptoms).
Priority Rule: "Seizure First, Pressure Next." When neuro symptoms are present in preeclampsia, preventing the seizure (with MgSO4 and precautions) is the immediate priority over lowering BP.
High-Frequency NCLEX Topics
Preeclampsia/Eclampsia is a High Yield topic. NCLEX frequently tests: 1) Identifying symptoms of severe disease/progression to eclampsia, 2) Prioritizing nursing actions (safety/seizure precautions first), 3) Understanding MgSO4 therapy (indications, monitoring, toxicity).
Watch Out for Question Variations!
* Instead of "priority intervention," the question may ask: "The nurse should prepare which medication?" Answer: Magnesium sulfate.
* The scenario may include platelets 80,000/mm3 and AST 200 U/L, testing knowledge of HELLP syndrome.
* A post-seizure scenario may ask for the immediate postictal action: Ensure airway patency and administer oxygen.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on the Labor & Delivery unit. A 34-week pregnant patient, Ms. Jones, is admitted with BP 170/110. She is holding her head, saying, "The light hurts my eyes, and I'm seeing spots." Her urine dip shows 3+ protein.Nursing Intervention Strategy:
1Immediate Action (Priority)Call for help. Gently guide Ms. Jones to a lateral position (prevents aspiration). Lower the bed, raise padded side rails. Dim the lights and minimize noise. Ensure the seizure cart (with oxygen, suction, airway equipment) and Magnesium sulfate are at bedside.
2AssessmentPerform a focused neuro assessment: check deep tendon reflexes (DTRs) for hyperreflexia, assess for clonus. Monitor vital signs continuously. Assess fetal heart rate (FHR) for signs of distress.
3Implementation of OrdersAdminister IV MgSO4 loading dose as prescribed (typically 4-6 g over 20-30 min). Then start maintenance infusion. Concurrently, administer prescribed antihypertensives (e.g., labetalol, hydralazine) to lower BP.
4Ongoing Monitoring & CareInsert an indwelling catheter for strict I&O (MgSO4 can cause urinary retention; output should be ≥30 mL/hr). Monitor for MgSO4 toxicity (check DTRs hourly, monitor respiratory rate >12/min, assess level of consciousness). Prepare patient and family for likely imminent delivery (cesarean or induction) once stabilized.
Patient Safety and Precautions:
* Key Point! Never leave a patient with signs of impending eclampsia alone.
* MgSO4 is a high-alert medication. Double-check pump settings and infusion rates.
* Contraindication: Do not give MgSO4 if DTRs are absent, respirations are <12/min, or urine output is inadequate.
1Loading Dose4-6 g in 100 mL IV fluid over 20-30 minutes.
2Maintenance Dose1-2 g/hour via infusion pump.
3Monitoring Parameters (Q1H or per protocol)* Respiratory Rate: Must be >12 breaths/min.
* Deep Tendon Reflexes (DTRs): Patellar reflex. Absent DTRs = First sign of toxicity.
* Urine Output: Must be ≥30 mL/hr.
* Serum Magnesium Level: Therapeutic range: 4-7 mg/dL. Toxic: >8-10 mg/dL.
4Antidote at BedsideCalcium gluconate 10% (1 g IV over 3-5 min) for signs of life-threatening toxicity.
A Word from Your Senior Nurse
Caring for a preeclamptic patient is about being a vigilant guardian for two lives. Those neuro symptoms are her body's screaming red flag. In clinical practice, you'll learn to move with calm urgency—setting up the quiet room, checking those reflexes, managing that MgSO4 drip like it's liquid gold. For the NCLEX, remember the mantra: "Neuro symptoms = Seizure precautions are priority #1." It's not just a test answer; it's the real-life sequence that keeps moms safe. You've got this!