,Finding Initial Status (Exhibit 1) Current Status (List) Status
Deep tendon reflexes 3+ bilaterally (Hyperreflexive) 2+ bilaterally Improved (Normal)
Respiratory rate Even, nonlabored (Normal) 18/min Stable/Improved
Blood pressure Implied high (severe preeclampsia/HELLP) 146/96 mm Hg Still High (Not improved)
Urine output Not specified initially 40 mL Borderline (Not a clear "improvement")
Temperature Not specified initially 38.3° C (101° F) Worse (Febrile)
Heart rate Regular (Normal) 58/min Worse (Bradycardic; possible Mg toxicity)
Oxygen saturation Not specified initially 95% on 2 L NC Worse (Requiring O2)
,
, Completed Sentence
"Based on the client findings, the nurse should first recommend seizure precautions and then prepare to assist with
administration of magnesium sulfate."
Rationale
1. Seizure Precautions: The client is showing signs of severe preeclampsia/HELLP syndrome. The immediate
priority is safety to prevent injury in the event of an eclamptic seizure.
2. Magnesium Sulfate: This is the drug of choice for the prevention and treatment of eclamptic seizures. While
delivery is the definitive "cure" for HELLP, stabilizing the mother with magnesium sulfate is a mandatory
first step in the acute phase of care.
The following actions should be included in the client's plan of care:
• [X] Monitor deep tendon reflexes: Essential to assess for magnesium sulfate toxicity and neuromuscular
irritability (risk of seizures/eclampsia).
• [X] Check urinary output: Crucial for monitoring renal function and assessing for oliguria, which is a sign
of worsening preeclampsia.
Deep tendon reflexes 3+ bilaterally (Hyperreflexive) 2+ bilaterally Improved (Normal)
Respiratory rate Even, nonlabored (Normal) 18/min Stable/Improved
Blood pressure Implied high (severe preeclampsia/HELLP) 146/96 mm Hg Still High (Not improved)
Urine output Not specified initially 40 mL Borderline (Not a clear "improvement")
Temperature Not specified initially 38.3° C (101° F) Worse (Febrile)
Heart rate Regular (Normal) 58/min Worse (Bradycardic; possible Mg toxicity)
Oxygen saturation Not specified initially 95% on 2 L NC Worse (Requiring O2)
,
, Completed Sentence
"Based on the client findings, the nurse should first recommend seizure precautions and then prepare to assist with
administration of magnesium sulfate."
Rationale
1. Seizure Precautions: The client is showing signs of severe preeclampsia/HELLP syndrome. The immediate
priority is safety to prevent injury in the event of an eclamptic seizure.
2. Magnesium Sulfate: This is the drug of choice for the prevention and treatment of eclamptic seizures. While
delivery is the definitive "cure" for HELLP, stabilizing the mother with magnesium sulfate is a mandatory
first step in the acute phase of care.
The following actions should be included in the client's plan of care:
• [X] Monitor deep tendon reflexes: Essential to assess for magnesium sulfate toxicity and neuromuscular
irritability (risk of seizures/eclampsia).
• [X] Check urinary output: Crucial for monitoring renal function and assessing for oliguria, which is a sign
of worsening preeclampsia.
