A nurse is preparing a client for discharge home after an admission for bilateral pulmonary emboli. The client is prescribed warfarin in addition to regular daily medications. Which of the following actions should the nurse take?

Rationale for Correct Choices:

• Evaluating the fetal heart rate tracing: The client’s report of decreased fetal movement and severe hypertension raises concern for fetal compromise. Immediate fetal assessment ensures the fetus is tolerating the intrauterine environment, especially before administering medications like magnesium sulfate.
• Administering magnesium sulfate IV: This is prescribed to prevent eclampsia, given the client’s severely elevated BP, hyperreflexia, and proteinuria. After confirming fetal status, seizure prophylaxis should be initiated without delay.

Rationale for Incorrect Choices:

• Administering acetaminophen PO: Although ordered for headache, the symptom is a manifestation of severe preeclampsia. Treating it symptomatically without addressing its cause could delay necessary critical interventions.
• Obtaining a 24-hour urine collection: Useful for confirming the extent of proteinuria, but not immediately necessary for clinical decision-making given existing positive findings.
• Inserting an indwelling urinary catheter: This supports fluid monitoring during magnesium therapy, but fetal assessment and seizure prevention take precedence.
• Administering betamethasone IM: Important for fetal lung development in preterm pregnancies, but it is not the immediate priority when there is a high risk for seizure or fetal distress.

Rationale for Correct Choices:

• Seizures: The client presents with severe preeclampsia, indicated by BP >160/110 mm Hg, 3+ proteinuria, hyperreflexia (patellar reflex 4+), and persistent headache. These are strong predictors of progression to eclampsia, which is marked by seizures.
• Placental Abruption: Severe hypertension increases the risk of placental abruption due to vascular compromise in the uteroplacental circulation. Decreased fetal movement may be an early warning sign of impaired placental perfusion or separation.

Rationale for Incorrect Choices:

• Cervical Insufficiency: This is a painless cervical dilation often leading to second-trimester loss, unrelated to hypertension or proteinuria. The client is in the third trimester with no signs of cervical changes.
• Hypoglycemia: The client has no history of diabetes, glucose intolerance, or related symptoms. Her urine glucose was only trace, and no medications suggest insulin use.
• Heart Failure: No signs of pulmonary congestion, dyspnea, or elevated heart rate are present. Oxygen saturation is normal, and breath sounds are not mentioned as abnormal, making CHF unlikely at this stage.