A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings is the nurse's priority?

Rationale for correct choices

• Placental abruption: The client presents at 30 weeks gestation with sudden onset right upper abdominal pain, headache, nausea, vomiting, facial edema, and elevated blood pressure (148/94 mm Hg). These are classic signs of preeclampsia, which significantly increases the risk of placental abruption. Abruptio placentae involves premature separation of the placenta from the uterine wall, leading to maternal and fetal complications, making close monitoring essential.

• Hypertension: The client’s elevated blood pressure is a hallmark feature of preeclampsia and a key risk factor for placental abruption. Hypertension can impair placental perfusion, increasing the likelihood of placental separation. Prompt identification and management of elevated blood pressure are critical to prevent adverse maternal and fetal outcomes.

Rationale for incorrect choices

• Spontaneous abortion: Spontaneous abortion usually occurs before 20 weeks gestation, whereas this client is at 30 weeks. Current symptoms are more indicative of a hypertensive pregnancy disorder rather than early pregnancy loss, making this diagnosis unlikely.

• Oligohydramnios: There is no indication of reduced amniotic fluid volume on assessment, and fundal height is consistent with gestational age. Oligohydramnios would require ultrasound confirmation and is not suggested by the client’s current presentation.

• Placenta previa: Placenta previa is characterized by painless vaginal bleeding rather than abdominal pain and elevated blood pressure. The client’s symptoms of right upper quadrant pain, hyperreflexia, and hypertension point toward preeclampsia-related complications rather than placenta previa.

• Chorioamnionitis: Chorioamnionitis is an intra-amniotic infection typically associated with fever, uterine tenderness, and maternal/fetal tachycardia. This client is afebrile with normal fetal heart rate, making chorioamnionitis unlikely.

• Hyperreflexia: While hyperreflexia is present, it is a sign of preeclampsia rather than a direct risk factor for placental abruption. It supports the diagnosis but does not independently cause the abruption.

• Temperature: The client’s temperature is within normal limits. Fever is not present and therefore does not contribute to the risk of placental abruption.

• Fundal measurement: The fundal height (29 cm) is appropriate for gestational age and does not indicate a risk factor for placental abruption. Fundal height alone is not predictive of this complication.

• Vomiting: Although present, vomiting is a nonspecific symptom and a secondary sign of preeclampsia. It contributes to maternal discomfort but is not a direct risk factor for placental abruption.

Rationale for correct choices

• Temperature 38.2° C (100.8° F): A temperature above 38° C after the first 24 hours postpartum is concerning for infection. This client has multiple risk factors including cesarean delivery and prolonged rupture of membranes. Fever in this patient warrants immediate evaluation for postpartum endometritis or mastitis.

• Heart rate 104/min: Tachycardia can indicate a systemic inflammatory or infectious process in the postpartum period. When paired with fever and uterine tenderness, it raises concern for sepsis or worsening uterine infection. Early recognition is critical to prevent complications.

• Client reports feeling unwell: A subjective report of feeling unwell is an important early sign of infection or systemic illness. This symptom, combined with abnormal vital signs and laboratory findings, suggests the client may be developing a postpartum complication requiring prompt intervention.

• Uterus firm at 1 cm above the umbilicus and tender to palpation: Uterine tenderness beyond the immediate postpartum period is abnormal and commonly associated with endometritis. The elevated fundal height also suggests delayed uterine involution, reinforcing concern for uterine infection.

• Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is a classic indicator of postpartum uterine infection. Normal lochia should not have an offensive odor, and this finding strongly supports suspected endometritis requiring immediate follow-up.

• WBC count 33,000/mm³: Although mild leukocytosis is expected postpartum, a WBC count this elevated exceeds normal physiologic changes. In the presence of fever and uterine findings, this level is highly suggestive of an acute infectious process.

Rationale for incorrect choices

• Breasts feel firm, heavy, and warm with moderate nipple discomfort: These findings are consistent with normal breast engorgement during early breastfeeding. While uncomfortable, they are expected postpartum changes and do not indicate infection in the absence of localized redness or systemic signs.

• Surgical incision well approximated with slight edema present: Mild edema without redness, drainage, or separation is a normal postoperative finding. There are no signs suggesting a surgical site infection at this time.

• Respiratory rate 18/min, BP 108/70 mm Hg, SaO₂ 97%: These vital signs fall within expected postpartum ranges and do not indicate acute instability. They do not contribute to the immediate concern for infection or deterioration.