1040: 16-year-old gravida 1 para 0, at 34 weeks gestation, reports a frontal headache and edema in the hands and face that started three days ago. Despite taking acetaminophen, she reports that the headache has not subsided. She rates her headache pain as 7 on a scale of 0 (no pain) to 10 (severe pain). The headache is getting so bad that she reports photophobia. She denies any abdominal (epigastric) pain, nausea, or vomiting. She reports missing her last two antepartum checkups because of the lack of transportation. Vital signs: T 97.7° F (36.5° C), P 95, RR 19, BP 141/92 mm Hg. Pulse oximetry 95% on room air. Dipstick urine analysis obtained showed proteinuria.
1140: Dipstick urine analysis obtained showed proteinuria. Fetal heart rate obtained via doppler ultrasound 134 beats-per-minute. Vital signs: T 97.7° F (36.5° C), P 92, RR 16, BP 144/94 mm Hg. Pulse oximetry 96% on room air.
1415: Bedside ultrasound completed. Vital signs: T 97.7° F (36.5° C), P 89, RR 15, BP 143/91 mm Hg. Pulse oximetry 95% on room air.
- Vital signs every two to four hours
- Obtain fetal heart rate
- Transabdominal ultrasound
- Obtain medical records from previous visits
The nurse reviews the nurse's note and discusses it with the physician
➢ For each assessment finding below, click to specify if the finding is consistent with the disease process of preeclampsia, severe preeclampsia, or eclampsia.
Each finding may support more than 1 disease process.
Note: Each column must have at least 1 response option selected
- A. blood pressure 143/91 mm Hg
- B. proteinuria
- C. no abdominal pain
- D. facial edema
- E. frontal headache
- F. photophobia
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