A nurse is caring for a client who is at 34 weeks of gestation.

The client reports headache, dizziness, and blurred vision for 1 week.

The nurse notes 3+ edema in lower extremities and deep tendon reflexes (DTRs) 3+ with positive clonus.

The fetal heart rate (FHR) is 140 with minimal variability.

The nurse is reviewing the client’s electronic medical record to develop a plan of care.

Which condition is the client most likely experiencing, what are two actions the nurse should take to

Choice A rationale 
The client’s symptoms of headache, dizziness, blurred vision, 3+ edema in lower extremities, deep tendon reflexes (DTRs) 3+ with positive clonus, and a fetal heart rate (FHR) of 140 with minimal variability are indicative of preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. It usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious complications for both the mother and baby. To address this condition, the nurse should: Monitor the client’s blood pressure regularly. Administer prescribed medications to control blood pressure and prevent seizures. The nurse should monitor the following parameters to assess the client’s progress: Blood pressure readings: Regular monitoring can help detect any sudden increases, which could indicate worsening preeclampsia. Urine protein levels: Protein in the urine is a common sign of preeclampsia and should be monitored regularly. 
Choice B rationale 
Chronic hypertension is a possibility, but it does not fully explain the client’s symptoms. While chronic hypertension can cause headaches and dizziness, it does not typically cause 3+ edema in the lower extremities or positive clonus. Furthermore, chronic hypertension would have been present before the pregnancy or diagnosed before the client reached 20 weeks of gestation. 
Choice C rationale 
While the client’s symptoms of headache, dizziness, and blurred vision could suggest a neurologic issue, the presence of 3+ edema in the lower extremities and positive clonus are more indicative of preeclampsia. Neurologic status would be monitored as part of the care for a client with preeclampsia. 
Choice D rationale 
Liver function studies would be relevant if there were symptoms or signs suggesting liver involvement such as upper right abdominal pain, nausea or vomiting, or jaundice. However, the client’s symptoms are more indicative of preeclampsia.