A nurse in prenatal clinic is assessing a woman at 34 weeks’ gestation. The client’s blood pressure is 166/100 mm Hg and her urine is +3 for protein. She states that she has a severe headache and occasional blurred vision. Her baseline blood pressure was 100/62 mm Hg. What is priority nursing action?

The priority nursing action in this scenario, given the woman's symptoms and clinical findings at 34 weeks' gestation—a blood pressure of 166/100 mm Hg, urine +3 for protein, a severe headache, and occasional blurred vision—would be:

• Arrange transportation to the hospital.

Rational:-

• The presentation suggests that the client may be experiencing preeclampsia with severe features, which is a serious condition that requires immediate medical evaluation and often hospitalization.
• The significant increase from her baseline blood pressure, proteinuria, severe headache, and visual changes are all worrisome signs that warrant urgent attention to prevent complications for both the mother and the baby.
• Preeclampsia can progress quickly and can lead to eclampsia, which can have severe or even fatal complications if not treated promptly.

Key Points

• While obtaining a prescription for an antihypertensive (Option 2) and rechecking the blood pressure within half an hour (Option 3) are important considerations in managing hypertension in pregnancy, these actions should occur after the woman has been transported to a hospital where complete assessment and appropriate management, including possibly emergency delivery, can be provided.
• Option 4, obtaining a prescription for acetaminophen to relieve the headache, does not address the underlying cause and urgency of the situation. 

Immediate hospital assessment and care are crucial in managing this situation to ensure the safety and well-being of both the mother and the fetus.