The nurse identifies assessment findings for an African-American client with preeclampsia. Blood pressure is 158/100 mmHg; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+; 1+ edema hands, feet, ankles
On the next hourly assessment, which new assessment finding would indicate worsening of the condition?
A) Blood pressure 158/100 mmHg
B) Platelet count 150,000
C) Urinary output 20 mL/hour
D) Reflexes 2+
Answer: C
The decrease in urine output is an indication of decrease in glomerular filtration rate, which indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is the urine output change. The blood pressure increase is not significant. The reflexes are normal at 2+. The platelet count is normal, though it is at the lower end.
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