The nurse is assessing a client who has severe preeclampsia. The assessment finding that should be reported to the physician is:
1. Proteinuria.
2. Platelet count of 20,000.
3. Urine output of 50 ml per hour.
4. 21 DTRs.
2
Rationale 1: The 11 spilling of protein is abnormal, but this is acceptable for a client with preeclampsia.
Rationale 2: The client could be experiencing HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). This condition is sometimes associated with severe preeclampsia, and women who experience this multiple-organ-failure syndrome have high morbidity and mortality rates. A platelet count lower than 20,000 is critically low.
Rationale 3: A urine output of at least 30 ml/hour is normal.
Rationale 4: The DTRs of 21 are normal.
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