Exhibits

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Assessment	Findings
Nurses' Notes	Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. Membranes intact No uterine contractions noted.

	FHR baseline 138, minimal variability. No further reports of burning with urination.
Laboratory Results	WBC 12,000/mm2 (5,000 to 10,000/mm3) Platelet count 188,000/mm3 (150,000 to 400,000/mm3)
Vital Signs	Temperature 37.1° C (98.7° F) Blood pressure 120/78 mm Hg

A. Faintness upon rising is a common symptom during pregnancy, typically due to orthostatic hypotension, and does not necessarily require reporting unless it is persistent or severe.
B. Bleeding gums can occur due to hormonal changes and is usually not a cause for concern.
C. Swelling of the face could indicate preeclampsia, a potentially serious condition that should be reported to the provider immediately.
D. Urinary frequency is a normal finding during pregnancy and does not need to be reported unless associated with other symptoms such as pain or fever.

1. Perform suctioning

Contraindicated

Suctioning can be a stressor to the body, and in patients with autonomic dysreflexia, it could potentially exacerbate the condition and lead to further increases in blood pressure. In autonomic dysreflexia, managing the underlying trigger (such as a full bladder or bowel impaction) is key, not suctioning unless there is a specific need related to respiratory issues. This action could make the elevated blood pressure worse.
2. Withhold pain medication for headache until other manifestations resolve

Contraindicated
Pain management is critical in a patient with autonomic dysreflexia. The headache is a significant symptom of autonomic dysreflexia and needs to be addressed immediately, as pain is often the trigger. Withholding pain medication could worsen the client's symptoms and contribute to further complications. Proper management of pain should occur concurrently with interventions to address the elevated blood pressure.
3. Assess blood pressure every 15 minutes

Anticipated
Monitoring blood pressure is crucial in patients with autonomic dysreflexia to track changes and assess for improvement or worsening of hypertension. The nurse should frequently assess the client’s blood pressure to ensure it is returning to normal after appropriate interventions are initiated. Autonomic dysreflexia requires continuous monitoring of blood pressure to avoid complications such as stroke or cardiac events.
4. Administer nifedipine

Contraindicated
While nifedipine (a calcium channel blocker) is used to manage hypertension, it is not typically recommended as a first-line treatment for autonomic dysreflexia in spinal cord injury patients. Instead, interventions should focus on removing the triggering stimulus (e.g., bladder distension, constipation, or pressure ulcers). If blood pressure does not respond, other medications such as nitroglycerin or hydralazine may be used, but nifedipine is not the preferred option.
5. Assess for urinary retention

Anticipated
Urinary retention is a common trigger for autonomic dysreflexia in patients with spinal cord injuries, particularly those with injuries at or above T6. If the client is experiencing symptoms of autonomic dysreflexia, one of the first steps is to assess for urinary retention. If the bladder is full, catheterization may be required to relieve the pressure and help normalize the blood pressure. The nurse should assess the client’s urinary status promptly.
6. Place client in supine position

Contraindicated
In the case of autonomic dysreflexia, placing the client in a supine position could potentially worsen the elevated blood pressure by increasing venous return and making it harder for the body to normalize blood pressure. The client should be positioned sitting upright or at a 45-degree angle, which can help lower blood pressure by promoting venous pooling and reducing the effects of the autonomic dysreflexia response.