The nurse identifies the following assessment findings on a client with pre-eclampsia: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 11 on dipstick; and edema of the hands, ankles, and feet
On the next hourly assessment, which of the following new assessment findings would be an indication of worsening of the pre-eclampsia? 1. Blood pressure 158/104
2. Urinary output 20 mL/hour
3. Reflexes 21
4. Platelet count 150,000
2
Rationale:
1. The blood pressure has not had a significant rise.
2. The decrease in urine output is an indication of decrease in GFR, which indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is the urine output change.
3. The reflexes are normal at 21.
4. The platelet count is normal, though it is at the lower end.
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