A nurse is caring for a female client, age 30, at 37 weeks of gestation in the labor and delivery unit for blood pressure observation. Click to highlight the findings below that would indicate that the client is not progressing or has a potential problem. Client rested well during the night with blood pressures remaining below 160/110 mm Hg. Headache decreased in intensity at midnight. Client now rates their pain from headache as 7 on a scale of 0 to 10. Client reports that they continue to see “spots” in vision. Client rested well during the night with blood pressures remaining below 160/110 mm Hg. Headache decreased in intensity at midnight. Client now rates their pain from headache as 7 on a scale of 0 to 10. Urine output has ranged from 25 to 55 mL/hr.

Choice A rationale: Blood pressure readings below 160/110 mm Hg overnight indicate some level of blood pressure control, which is a positive sign in hypertensive pregnancy conditions. The goal is to maintain pressures below this threshold to reduce risk of end-organ damage. Stable or lower pressures reduce cerebral and placental ischemia risk. Therefore, resting well with controlled BP suggests no immediate worsening, indicating progression is stable at this point. Choice B rationale: A decrease in headache intensity temporarily is a favorable clinical sign. Headache in preeclampsia is caused by cerebral edema and vasospasm, so improvement indicates less neurological irritation or pressure. However, this is a transient improvement and must be interpreted cautiously, but the reduction alone does not indicate a worsening condition, so it is not a marker of poor progression. Choice C rationale: An increased headache intensity rating to 7/10 signals significant neurological involvement and increased cerebral irritation, typical of worsening preeclampsia or impending eclampsia. Severe headaches in pregnancy with hypertension indicate cerebral vasospasm or edema, which may lead to seizures if untreated. This is a critical sign requiring urgent intervention to prevent maternal and fetal morbidity. Choice D rationale: Persistent visual disturbances such as seeing spots or flashes are neurological symptoms indicating retinal or cerebral involvement due to vasospasm, ischemia, or edema. These symptoms are common in severe preeclampsia and herald worsening disease. Visual symptoms result from endothelial dysfunction affecting cerebral and retinal vessels, requiring immediate evaluation to prevent progression to eclampsia. Choice E rationale: Epigastric discomfort reflects stretching or ischemia of the liver capsule from hepatic involvement in severe preeclampsia or HELLP syndrome. This pain typically presents as right upper quadrant or epigastric pain due to hepatocellular injury or microvascular thrombosis. It is a warning sign of multisystem involvement and potential progression to life-threatening complications such as hepatic rupture. Choice F rationale: Hyperactive deep tendon reflexes (3+ to 4+) and positive clonus are clinical signs of central nervous system irritability caused by increased excitability of motor neurons. This occurs due to cerebral vasospasm and ischemia in severe preeclampsia and predicts risk for seizures (eclampsia). These neurological signs are crucial in assessing disease severity and necessitate urgent management. Choice G rationale: Urine output between 25 and 55 mL/hr approaches the lower limit of normal (normal ≥30 mL/hr). Reduced urine output in preeclampsia indicates renal hypoperfusion or injury due to endothelial dysfunction and vasospasm, which can progress to acute kidney injury. Monitoring urine output is essential as oliguria signals worsening renal compromise, increasing maternal and fetal risk.