A 28-year-old multigravida at 37 weeks’ gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/hour. The nurse has determined the priority nursing diagnosis to be: risk for central nervous system injury related to hypertension, edema of cerebrum. To maintain safety for this client, the nurse should: ¦ 1. Maintain continuous fetal monitoring. ¦ 2. Encourage family members to remain at bedside. ¦ 3. Assess reflexes, clonus, visual disturbances, and headache. ¦ 4. Monitor maternal liver studies every 4 hours.
The Correct Answer and Explanation is :
The correct answer is 3. Assess reflexes, clonus, visual disturbances, and headache.
Explanation:
In the case of severe preeclampsia, the priority is to prevent further complications like seizures, stroke, or central nervous system injury. Preeclampsia is characterized by high blood pressure and multi-organ involvement, including the central nervous system (CNS), liver, and kidneys. The nurse needs to focus on monitoring signs that may indicate impending seizure activity or worsening neurological status. Magnesium sulfate is used to prevent seizures in patients with severe preeclampsia, but close monitoring is still required for signs of magnesium toxicity or neurologic changes.
- Maintaining continuous fetal monitoring (Option 1) is important but not the priority in the context of preventing CNS injury in the mother. While fetal monitoring is essential to assess fetal well-being, the immediate concern in this case is the maternal condition and safety. The fetus should still be monitored, but maternal neurological status takes precedence in preventing complications like seizures.
- Encouraging family members to remain at bedside (Option 2) does not directly impact the maternal safety from a CNS injury. While family support is important, it does not provide the same level of monitoring or intervention to prevent further deterioration of the mother’s condition.
- Assessing reflexes, clonus, visual disturbances, and headache (Option 3) is the most appropriate action. These are signs of increasing CNS involvement, such as cerebral edema or the onset of eclampsia (seizures). Hyperreflexia and clonus can indicate impending seizures, and visual disturbances or headache can be warning signs of worsening hypertension or preeclampsia-related CNS changes. The nurse must monitor for these signs to intervene early and prevent life-threatening complications.
- Monitoring maternal liver studies every 4 hours (Option 4) is important for assessing the severity of preeclampsia and liver function, but it is not as urgent as the immediate neurological assessment. This monitoring is part of the broader management but does not take priority over assessing for CNS injury.
In summary, assessing neurological signs such as reflexes, clonus, visual disturbances, and headache (Option 3) is the best intervention to maintain safety for the mother in this case.