The nurse identifies the following assessment findings for an African American client with preeclampsia: 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 preeclampsia? 1. Blood pressure 158/100
2. Urinary output 20 mL/hour
3. Reflexes 21
4. Platelet count 150,000
2. Urinary output 20 mL/hour
Rationale:
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 21. The platelet count is normal, though it is at the lower end.
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