35 Weeks, a Severe Headache, and RUQ Pain
Ms. T, 34, G1P0 at 35 weeks' gestation, is admitted to the obstetric unit with a blood pressure of 168/112 mmHg on two readings 15 minutes apart. She reports a pounding headache that "didn't touch" with acetaminophen and sees flashing lights in her right eye. Dipstick shows 3+ proteinuria. Deep tendon reflexes are 3+ with clonus; she reports new right upper quadrant discomfort. Fetal heart rate is 145 with moderate variability. She is 4 cm dilated, 70% effaced, contracting every 6 minutes. The provider orders a magnesium sulfate bolus followed by infusion, PRN IV labetalol, and continuous fetal monitoring.
1. Which findings place her in the highest-risk category, and what is the immediate risk you are preventing?
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This is preeclampsia with severe features, and the immediate threat is seizure (eclampsia) and stroke.
- BP 168/112: systolic at least 160 and/or diastolic at least 110 defines a severe-range blood pressure requiring treatment.
- Headache unrelieved by acetaminophen and visual disturbance (flashing lights) = cerebral vasospasm/edema; these are classic impending-seizure symptoms.
- Right upper quadrant pain raises concern for hepatic involvement/HELLP - report it immediately and expect liver enzymes and platelets to be drawn.
- 3+ proteinuria and hyperreflexia with clonus support the diagnosis and show neuromuscular irritability.
The judgment: her blood pressure and symptoms outrank her contraction pattern and dilation. A client can be in early labor and still be the most unstable person on the unit - the magnesium bolus and blood pressure treatment come first, and delivery planning follows.
2. What assessments and safety measures do you build into the shift while she is on magnesium sulfate?
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Magnesium sulfate is a high-alert drug, so monitoring is the intervention.
Baseline and ongoing assessment:
- Deep tendon reflexes, respiratory rate and effort, level of consciousness, and urine output (at least 30 mL/hr) - check hourly during infusion; magnesium is renally cleared, so oliguria means accumulation.
- Vital signs including BP per protocol, continuous fetal monitoring, and periodic serum magnesium levels when ordered.
- Auscultate lungs for crackles and watch for edema - magnesium and fluid can tip a client toward pulmonary edema.
Toxicity recognition (report and stop the infusion):
- Loss of deep tendon reflexes, respiratory rate below 12, oliguria, drowsiness, or slurred speech.
Safety setup:
- Calcium gluconate at the bedside as the antidote before the infusion is started; know its location.
- Seizure precautions: padded side rails, bed low, call light in reach, minimal stimulation, quiet room, suction and oxygen available.
- IV access verified (large bore, patent), infusion on a pump, and site checked for infiltration.
Do not delegate any of this to the UAP beyond fetching supplies and reporting vital signs.
3. Her sister asks, "Why can't they just take the baby now and stop all this?" It is 0300 and the client reports the RUQ pain is worse. What do you do?
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Assess and escalate first, then teach.
- Reassess Ms. T: RUQ pain worsening can signal hepatic capsule involvement or progression toward HELLP - get a full set of vitals, repeat reflexes, ask about nausea, visual change, and epigastric pain, and look at the fetal monitor tracing.
- Notify the provider now with specifics: worsening RUQ pain, current BP, reflex/clonus findings, urine output, and the fetal tracing. Anticipate stat labs (CBC with platelets, AST/ALT, LDH, uric acid) and discuss delivery timing, which is the definitive treatment.
- Answer the sister honestly but within your role: "The team is weighing delivering the baby against the risks of being born at 35 weeks, and the medicine she is getting is what prevents a seizure. Your job right now is to stay calm and let her rest - I'll tell you what I know as soon as I know it." Do not promise a delivery time or a specific outcome; do not discuss details the client has not authorized.
- Protect the client from stimulation: limit visitors as needed, dim lights, cluster care.
- Document the change, the notification, and the response.
The tested judgment is recognizing that a family member's pressure does not change the clinical priority - a worsening symptom in a severely preeclamptic client is a reportable event, and the nurse does not soften it to comfort a relative.