A practical nurse (PN) in an outpatient prenatal clinic is collecting data from a client at 34 weeks gestation. The client reports a severe, persistent headache and seeing "dark spots." The PN obtains a blood pressure reading of 168/112 mm Hg and a urine dipstick revealing 3+ proteinuria. Which actions should the PN take? Select all that apply.
- Notify the registered nurse and healthcare provider immediately about the clinical findings.Answer
- Assist the client into a quiet, dimly lit examination room to rest.Answer
- Apply an external electronic fetal monitor to assess the fetal heart rate and uterine activity.Answer
- DAdminister the facility's standing order for intravenous push labetalol.
- EHave the client rest in the waiting area and reassess the blood pressure in 30 minutes before reporting.
- FReassure the client that visual changes are a normal physiological adaptation of the late third trimester.
Answer
The correct actions are to notify the registered nurse and healthcare provider immediately, assist the client into a quiet and dimly lit room, and apply an external electronic fetal monitor.
The client is exhibiting clear signs of severe preeclampsia (blood pressure greater than 160/110 mm Hg, 3+ proteinuria, persistent headache, and visual disturbances), which constitutes a medical emergency. The practical nurse must immediately notify the registered nurse and healthcare provider so collaborative, advanced treatment can begin. Placing the client in a quiet, dimly lit room implements seizure precautions by proactively reducing central nervous system stimulation. Applying an electronic fetal monitor is well within the practical nurse's scope for data collection and is absolutely essential to evaluate how the fetus is tolerating the severe maternal hypertension.
Step-by-Step Solution
Key Concept
Recognition and initial management of severe preeclampsia within the practical nurse scope of practice.
Estimated Time:1m 30s