A nurse is admitting a female client, age 34, who is at 38 weeks of gestation to the labor and delivery unit for induction of labor.

Which of the following actions should the nurse take prior to implementing the provider’s prescriptions?

Choice A rationale: The client exhibits signs consistent with severe preeclampsia including blood pressure above 160/110 mm Hg, 3+ to 4+ deep tendon reflexes, and positive clonus, which are neurological indicators of central nervous system irritability. These findings increase the risk for eclamptic seizures. The headache, visual disturbances (“spots”), and epigastric pain further indicate imminent seizure risk from cerebral edema and vasospasm. Early intervention is crucial to prevent progression to eclampsia.

Choice B rationale: Elevated blood pressure combined with preeclampsia significantly raises the risk of abruptio placentae, the premature separation of the placenta from the uterine wall. This occurs because hypertension causes vasospasm and weakening of the placental attachment, increasing placental insufficiency and hemorrhage. The client’s edema and headache indicate vascular endothelial dysfunction, contributing to this risk. Abruptio placentae is a critical obstetric emergency requiring urgent recognition.

Choice C rationale: The client’s symptoms and signs of hypertension, headache, epigastric pain, and elevated blood pressure with edema suggest progression toward HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). Although labs are not provided, the clinical presentation fits the syndrome’s prodromal phase. HELLP syndrome is a severe variant of preeclampsia with hepatic involvement, which can cause multiorgan dysfunction and increased maternal-fetal morbidity if untreated.

Choice D rationale: Polyuria, or excessive urine output, is not typical in preeclampsia or related hypertensive disorders; instead, oliguria (decreased urine output below 30 mL/hr) may occur due to renal impairment. The client’s urine output of 25–55 mL/hr borders low normal, signaling possible kidney hypoperfusion, but polyuria is not a recognized complication here. Polyuria is more associated with diabetes or diuretic therapy, not hypertensive pregnancy disorders.

Choice E rationale: Ketoacidosis is metabolic acidosis due to ketone accumulation from uncontrolled diabetes or starvation. This client has no history or symptoms of diabetes or starvation, and no laboratory evidence of hyperglycemia or acidosis is reported. Ketoacidosis is not a complication linked to preeclampsia or hypertension in pregnancy and is therefore unlikely in this case.

Choice F rationale: Fetal macrosomia is excessive fetal growth usually related to maternal diabetes or obesity. This client has no indications of gestational diabetes or excessive fetal growth; fetal heart rate and contractions are within normal limits, and no mention of abnormal fundal height or ultrasound findings is given. The mild hypertension and edema do not predispose to macrosomia.

Choice A rationale

Urinary output of 20 mL/hr is indicative of oliguria, which is a significant adverse effect of magnesium sulfate therapy. Magnesium is renally excreted, and decreased urinary output can lead to magnesium toxicity. The desired urinary output for a client receiving magnesium sulfate should be at least 25 to 30 mL/hr to ensure adequate drug excretion.

Choice B rationale

Fetal heart rate pattern with minimal variability is a concerning finding and can indicate central nervous system depression in the fetus, potentially due to excessive magnesium levels. Normal fetal heart rate variability reflects a healthy autonomic nervous system. Magnesium sulfate's therapeutic effect is on the mother, not directly on fetal heart rate variability.

Choice C rationale

A change in fetal heart rate from 150/min to 166/min, while still within the normal range (110-160 bpm), does not directly indicate the desired therapeutic effect of magnesium sulfate for preeclampsia. This fluctuation could be due to various factors and is not a primary indicator of successful seizure prophylaxis or blood pressure control.

Choice D rationale

Magnesium sulfate is a central nervous system depressant that works by blocking neuromuscular transmission, thereby reducing hyperreflexia associated with preeclampsia. A decrease in deep tendon reflexes from 4+ (hyperactive) to 2+ (normal) indicates that the medication is achieving its desired therapeutic effect of central nervous system depression and reducing seizure risk.