A 36-year-old client at 38 weeks of gestation arrives at the clinic reporting a persistent headache, visual changes, and swelling in her hands and feet. Her blood pressure is 160/100 mmHg. What is the nurse's priority action?
Reassure the client about her symptoms in late pregnancy and recommend hydration.
Request lab work for liver enzymes and kidney function before notifying the provider.
Recommend that the client monitor her blood pressure at home and return for evaluation if her symptoms worsen.
Assess for other signs of preeclampsia and notify the provider promptly.
The correct response is to assess for other signs of preeclampsia and notify the provider. Preeclampsia is a potentially life-threatening condition characterized by severe hypertension, proteinuria, and end-organ damage. The provider must be informed to initiate appropriate interventions, such as maternal and fetal monitoring or medication to lower blood pressure. Reassuring the client or delaying further evaluation could place the client and fetus at risk. While lab work is important to confirm the diagnosis of preeclampsia, failure to escalate care without physician notification is a critical oversight.
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