The RN interprets the following external fetal monitoring strip as:

Rationale for correct condition: The client presents with a history of chronic hypertension, headache, visual disturbances, upper abdominal discomfort, and elevated blood pressure. Diagnostic results show elevated uric acid, proteinuria, and decreased platelet count. Physical examination reveals facial swelling, trace pitting edema, and hyperreflexia with clonus. These findings indicate preeclampsia, a condition of elevated blood pressure and proteinuria after 20 weeks of gestation. Preeclampsia may lead to severe complications if untreated.

Rationale for actions:

• Administering magnesium sulfate helps prevent seizures associated with severe preeclampsia.
• Preparing for immediate delivery is necessary if preeclampsia poses a severe risk to the mother or fetus.

Rationale for parameters:

• Monitoring blood pressure trends is crucial to manage and prevent severe hypertensive complications.
• Checking platelet count helps detect worsening coagulopathy, which is common in preeclampsia.

Rationale for incorrect conditions:

• Gestational hypertension: It lacks proteinuria and does not fully account for symptoms like severe headache and visual disturbances.
• HELLP syndrome: Although it shares similarities, HELLP would present with more severe hemolysis and liver involvement.
• Placental abruption: This condition would present with vaginal bleeding and abdominal pain, which are not reported in this case.

Choice A rationale

Observing the perineum for signs of crowning is important, but it doesn’t address the immediate need to manage the client’s urge to push. By the time crowning is visible, delivery is imminent, and the urge to push should have been managed earlier.

Choice B rationale

Helping the client to the bathroom to void might relieve some pressure but is not the immediate priority when the client feels the urge to push. Voiding can wait until contractions are managed.

Choice C rationale

Assisting the client into a supine position is not ideal for managing the urge to push. A supine position can increase discomfort and does not facilitate optimal delivery dynamics.

Choice D rationale

Assisting the client with quick shallow breathing helps manage the urge to push and prevents premature pushing, reducing the risk of cervical injury and aiding controlled delivery.