A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
A. Providing a calm environment
B. Obtaining a diet history
C. Administering an analgesic
D. Assessing fetal heart tones
Correct Answer: A. Providing a calm environment
A calm environment is needed to prevent seizure activity. Any stimulation can precipitate seizures. Establish measures to lessen likelihood of seizures; i.e., keep the room quiet and dimly lit, limit visitors, plan and coordinate care, and promote rest. Lessens environmental factors that may stimulate irritable cerebrum and cause a convulsive state.
Option B: Obtaining a diet history should be done later. Determine patient’s nutritional status, condition of hair and nails, and height and pregravid weight. Establishes guidelines for determining dietary needs and educating the patient. Malnutrition may be a contributing factor to the onset of PIH, specifically when the client follows a low-protein diet, has insufficient caloric intake, and is overweight or underweight by 20% or more before conception.
Option C: Administering an analgesic is not indicated because there is no data in the stem to indicate pain. MgSO4 a CNS depressant, decreases acetylcholine release, blocks neuromuscular transmission, and prevents seizures. It has a transient effect of lowering BP and increasing urine output by altering vascular response to pressor substances. Although IV administration of MgSO4 is easier to regulate and reduces the risk of a toxic reaction, some facilities may still use the IM route if continuous surveillance is not possible and/or if appropriate infusion apparatus is not available.
Option D: Assessing the fetal heart tones is important, but this is not the highest priority in this situation as stated in answer D. Assess for signs of impending eclampsia: hyperactivity of deep tendon reflexes (3+ to 4+), ankle clonus, decreased pulse and respirations, epigastric pain, and oliguria (less than 50 ml/hr).