A nurse is measuring the fundal height of a client who is at 36 weeks of gestation. The client suddenly reports nausea. Which of the following actions should the nurse take?

A. Esophagitis: Esophagitis is not a common manifestation of systemic lupus erythematosus (SLE). It is more often associated with gastroesophageal conditions or certain medications rather than autoimmune flare-ups.
B. Fever: Fever is a common finding during an acute exacerbation of SLE, reflecting the inflammatory nature of the autoimmune response and potential systemic involvement, such as joint pain or organ inflammation.
C. Diplopia: Diplopia, or double vision, is more associated with neurological conditions like multiple sclerosis rather than SLE, which more commonly affects joints, skin, and internal organs.
D. Bradykinesia: Bradykinesia is characteristic of Parkinson’s disease and other movement disorders, not typically seen in clients experiencing an SLE flare.

Rationale for Correct Choices:

• DTR 2+ bilaterally: The deep tendon reflexes improved from 1+ earlier (indicating possible magnesium toxicity) to 2+, which falls within the normal range of 1+ to 3+. This suggests better neuromuscular function and reduced magnesium side effects.
• Urine output 40 mL/hr: Increased from a low 20 mL/hr at 1400 to 40 mL/hr at 1800, above the normal minimum urine output (>30 mL/hr). This reflects improved renal perfusion and fluid balance, crucial for preventing complications in preeclampsia.
• Oxygen saturation 95% on 2 L nasal cannula: Oxygen saturation stabilized at 95%, which is the lower limit of normal (95–100%). Previously it was 92% on room air, indicating improved oxygenation with supplemental oxygen support.
• Respiratory rate 18/min: Improved from shallow respirations at 14/min to 18/min, which falls within the normal adult range (12–20/min). This indicates better respiratory effort and gas exchange.
• Blood pressure 146/96 mm Hg: Decreased from a hypertensive crisis level of 170/112 mm Hg at 1400 to 146/96 mm Hg, showing effective blood pressure management though still above the ideal (<120/80 mm Hg). This reduction lowers the risk of severe complications.

Rationale for Incorrect Choices:

• Temperature 38.3° C (101° F): Elevated above the normal range (36.5–37.5° C), this fever suggests possible infection or inflammatory response and does not represent clinical improvement. It requires further evaluation and treatment.
• Heart rate 58/min: Decreased from 80/min to 58/min, falling below the normal range of 60–100/min. This bradycardia may be a sign of magnesium toxicity or cardiovascular suppression and requires close monitoring.