A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate.
Select all nursing interventions that apply in the care for the client.

Choice A rationale

Pounding headache, visual changes, and epigastric pain in a patient with pregnancy-induced hypertension (PIH), now known as gestational hypertension or preeclampsia, are classic signs of worsening disease and indicate central nervous system irritability and potential hepatic involvement. These symptoms suggest the condition is progressing towards severe preeclampsia and increase the risk of eclampsia, which is characterized by seizures.

Choice B rationale

Magnesium sulfate is used to prevent seizures in severe preeclampsia. While it can cause side effects such as flushing, warmth, and muscle weakness, it does not typically cause pounding headache, visual changes, or epigastric pain. These symptoms are more indicative of the underlying disease process rather than the treatment.

Choice C rationale

Anxiety due to hospitalization can cause various symptoms, but the specific combination of pounding headache, visual changes, and epigastric pain is more strongly associated with the physiological changes occurring in worsening preeclampsia rather than solely psychological distress.

Choice D rationale

Gastrointestinal upset can cause epigastric pain, but it would not typically be accompanied by pounding headache and visual changes in the context of pregnancy-induced hypertension. The constellation of these symptoms strongly points towards a worsening of the hypertensive condition and potential end-organ involvement. .

Upon reviewing the client’s medical record, the nurse determines that the client is at risk for developing choriocarcinoma and thyrotoxicosis.

Rationale for correct answers

Choriocarcinoma is a malignant form of gestational trophoblastic disease (GTD) that arises from a molar pregnancy, as evidenced by grape-like vesicles seen on ultrasound and excessively elevated beta-hCG (normal in pregnancy: up to 100,000 mIU/mL by late first trimester). This condition can lead to metastases if not diagnosed and treated promptly.

Thyrotoxicosis occurs due to excess beta-hCG, which stimulates thyroid hormone production. This is supported by the slightly elevated free T4 levels, a common feature of molar pregnancy-related hyperthyroidism.

Rationale for incorrect Response 1 options

• Preterm labor: The client is at 20 weeks with no contractions noted, and cervical changes are not reported.
• Placenta previa: Characterized by painless bright red bleeding later in pregnancy; this client has dark brown discharge consistent with molar pregnancy.
• Cardiac arrhythmia: No evidence of electrolyte abnormalities or arrhythmogenic conditions such as hyperkalemia.

Rationale for incorrect Response 2 options

• Preeclampsia: Normal blood pressure (≥140/90 mm Hg would be concerning); no proteinuria.
• Urinary tract infection: No leukocytes, nitrites, or dysuria reported.
• Hypoglycemia: Normal serum glucose levels; vomiting history does not indicate hypoglycemia.