A nurse is caring for a client who is pregnant. The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
Explanation & Rationale
A. Urine protein: The presence of 3+ protein in the urine is abnormal and indicates significant proteinuria, which is a key sign of preeclampsia. Monitoring protein levels is essential for detecting kidney involvement and assessing maternal and fetal risk. B. Report of headache: A severe headache unrelieved by acetaminophen in a pregnant client with elevated blood pressure is a concerning symptom of preeclampsia. It can indicate cerebral involvement and increased risk for complications such as eclampsia or stroke. D. Fetal activity: Decreased fetal movement is an important sign of potential fetal compromise. Reduced activity may indicate fetal distress or hypoxia, requiring prompt assessment and possible intervention. E. Blood pressure: A blood pressure reading of 162/112 mm Hg is significantly elevated and meets criteria for severe preeclampsia. Hypertension during pregnancy can lead to maternal and fetal complications, making this a critical finding to address immediately.