The nurse is reviewing the client's prescriptions.

The nurse is administering medications to the client and is monitoring potential adverse effects of medications.

For each body system below, click to specify the assessment findings that could indicate a serious adverse reaction. Each body system may support more than 1 potential assessment finding. To deselect a finding. click on the finding again.

Body system	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Darkening of the urine Urinary frequency

Rationale for correct choices:

• Deep tendon reflexes 2+ bilaterally: DTRs decreased from 3+ to 2+, indicating reduced hyperreflexia. Hyperreflexia is a hallmark of preeclampsia and HELLP syndrome; improvement suggests that neuromuscular excitability and central nervous system irritability are stabilizing. Monitoring DTRs helps evaluate treatment effectiveness and risk reduction for complications.

• Oxygen saturation (SaO₂) 95% on 2 L nasal cannula: Oxygenation is within acceptable limits for a patient on supplemental oxygen. Maintaining adequate maternal oxygenation supports fetal perfusion and reduces hypoxic stress. Improved oxygen saturation reflects better respiratory status and cardiovascular stability compared with prior readings (SaO₂ 92–94%).

• Respiratory rate 18/min: The client’s respiratory rate is within normal limits, improving from earlier tachypnea (24/min). Stabilization of respiratory rate indicates reduced distress, better oxygenation, and improved overall maternal status, which contributes to safer outcomes for both mother and fetus.

• Blood pressure 146/96 mm Hg: At 1400, the client’s blood pressure had spiked to a very dangerous 170/112 mm Hg (severe hypertension). The decrease to 146/96 mm Hg by 1800 indicates that medical interventions are successfully lowering the pressure toward a safer range.

Rationale for incorrect choices:

• Temperature 38.3° C (101° F): The client’s temperature is elevated, indicating fever. Fever does not reflect improvement and may signal infection, inflammation, or other complications. Ongoing assessment and intervention are required to address the cause of hyperthermia.

• Urine output 40 mL: A single low urine output reading suggests oliguria, which is concerning in preeclampsia or HELLP syndrome. Adequate renal perfusion is essential; this value does not indicate improvement and requires ongoing monitoring.

• Heart rate 58/min: Bradycardia may be related to medications, vagal stimulation, or underlying cardiovascular changes. While it is a change from prior tachycardia, bradycardia itself is not an indicator of improvement and may require further evaluation.

A. Respiratory data: The client’s respirations are even and nonlabored, with clear lung sounds and an oxygen saturation of 94% on room air. Although the respiratory rate is mildly elevated, there are no signs of pulmonary edema or respiratory compromise requiring immediate follow-up.

B. Lower extremity data: The presence of 1+ dependent edema bilaterally can be a normal finding in pregnancy due to increased fluid volume and venous stasis. In isolation, this level of edema does not indicate a critical concern requiring urgent follow-up.

C. Nausea: Nausea and vomiting in the third trimester, especially when accompanied by headache and right epigastric pain, are concerning for severe preeclampsia. These symptoms suggest hepatic involvement and warrant prompt follow-up and evaluation.

D. Deep tendon reflex: Hyperreflexia with 3+ deep tendon reflexes indicates increased neuromuscular irritability. This finding is associated with preeclampsia and increases the risk for seizure activity, making it a priority for follow-up.

E. Blood pressure: A blood pressure of 156/96 mm Hg meets the criteria for hypertension in pregnancy. Persistent elevations place the client at risk for preeclampsia and related complications and require immediate provider notification.

F. Fundal height: At 30 weeks’ gestation, an expected fundal height is approximately 30 cm. A measurement of 26 cm suggests possible intrauterine growth restriction, which may be related to placental insufficiency and requires further assessment.

G. Weight data: A weight gain of 0.68 kg (1.5 lb) in one week may indicate abnormal fluid retention. Rapid weight gain in pregnancy is a concerning sign of worsening preeclampsia and should be followed up promptly.