The nurse is assessing a client who has severe pre-eclampsia. The assessment finding that should be reported to the physician is:
1. 11 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 pre-eclampsia.
2. The client could be experiencing HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). This condition is sometimes associated with severe pre-eclampsia, 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.
3. The urine output of .30 cc/hour is normal.
4. The DTRs of 21 are normal.
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