Initial client assessment shows BP 160/110 mm Hg, pulse 88, respirations 22, reflexes +3/+4 with 2 beat clonus, +3 protein in urine. Based on these findings, which complaints are most likely?

Initial client assessment shows BP 160/110 mm Hg, pulse 88, respirations 22, reflexes +3/+4 with 2 beat clonus, +3 protein in urine. Based on these findings, which complaints are most likely?

• A. Headache, blurred vision, and facial and extremity swelling
• B. Numbness and tingling in hands
• C. Severe abdominal pain
• D. Chest pain

Answer: (A)

High blood pressure in pregnancy with significant proteinuria and signs of CNS irritability points to severe preeclampsia. The headaches and visual disturbances arise from cerebral vasospasm and cerebral edema, while facial and extremity swelling reflect generalized edema from endothelial dysfunction. Together, these findings explain why headaches, blurred vision, and swelling are the most likely complaints. Numbness and tingling are not as characteristic of preeclampsia, though peripheral symptoms can occur in other conditions. Severe abdominal or chest pain can occur in pregnancy-related emergencies but do not fit the most immediate CNS and edema-clinical picture here.

High blood pressure in pregnancy with significant proteinuria and signs of CNS irritability points to severe preeclampsia. The headaches and visual disturbances arise from cerebral vasospasm and cerebral edema, while facial and extremity swelling reflect generalized edema from endothelial dysfunction. Together, these findings explain why headaches, blurred vision, and swelling are the most likely complaints.

Numbness and tingling are not as characteristic of preeclampsia, though peripheral symptoms can occur in other conditions. Severe abdominal or chest pain can occur in pregnancy-related emergencies but do not fit the most immediate CNS and edema-clinical picture here.