# A pregnant client at 34 weeks gestation reports a severe headache and blurred vision. The blood pressure is 164/108 mm Hg. What is the nurse's priority action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394058&lang=en  
> language: en  
> subject: Lifestyle Choices  
> category: HPM

## Question

A pregnant client at 34 weeks gestation reports a severe headache and blurred vision. The blood pressure is 164/108 mm Hg. What is the nurse's priority action?

## Option

1. Notify the provider and prepare for further evaluation of preeclampsia. **✔ Correct answer**
2. Reassure the client that headaches are expected late in pregnancy.
3. Encourage the client to walk for 20 minutes and recheck blood pressure.
4. Offer a low-sodium snack and discharge the client home.

**Correct answer: 1**

## Explanation

Severe hypertension with headache and visual symptoms suggests preeclampsia with severe features. The nurse should notify the provider and prepare for urgent evaluation and management. Reassurance, exercise, or discharge can delay treatment and increase maternal and fetal risk.

## In-depth explanation

Clinical Judgment
In pregnancy, severe blood pressure plus neurologic symptoms is a danger pattern.

Memory Tip
Headache, vision, high BP: think preeclampsia.

## Clinical scenario

Clinical Practice Guide
Preeclampsia warning signs include severe headache, visual changes, severe hypertension, abdominal pain, and swelling with pregnancy risk context.

Caution
Do not treat severe symptoms as routine pregnancy discomfort.

## Key concepts

- **Preeclampsia** — A pregnancy disorder involving hypertension and potential organ dysfunction.
- **Severe Features** — Findings such as severe blood pressure, neurologic symptoms, or organ injury.
- **Blurred Vision** — A visual symptom that can signal neurologic involvement in preeclampsia.

## Related questions

- [One hour after birth, a postpartum client has heavy lochia and a boggy uterus above the um…](https://mymerci.kr/pages/nclex_q.php?qn_id=393888&lang=en)
- [A pregnant client at 34 weeks gestation reports a severe headache and blurred vision. The …](https://mymerci.kr/pages/nclex_q.php?qn_id=394059&lang=en)
- [The nurse teaches parents of a 3-day-old newborn about jaundice. Which finding should the …](https://mymerci.kr/pages/nclex_q.php?qn_id=394157&lang=en)
- [A pregnant client at 32 weeks reports a severe headache and visual spots. Which instructio…](https://mymerci.kr/pages/nclex_q.php?qn_id=397170&lang=en)
- [A pregnant client at 32 weeks reports a severe headache and visual spots. Which instructio…](https://mymerci.kr/pages/nclex_q.php?qn_id=397171&lang=en)
- [A parent of a 2-day-old newborn asks why the baby's skin looks yellow. Which response shou…](https://mymerci.kr/pages/nclex_q.php?qn_id=397285&lang=en)
- [A breastfeeding client has mastitis and asks whether to stop feeding from the affected bre…](https://mymerci.kr/pages/nclex_q.php?qn_id=397341&lang=en)
- [A breastfeeding client has mastitis and asks whether to stop feeding from the affected bre…](https://mymerci.kr/pages/nclex_q.php?qn_id=397342&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=394058&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=394058&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=394058&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=394058&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=394058&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._