A laboring client with preeclampsia: which assessment finding is most significant for planning care?

• A. Blood pressure 158/80
• B. Four-hour urine output 240 ml
• C. Respiration 12/min
• D. Patellar reflex 4+

Answer: (D)

Hyperreflexia signals central nervous system irritability in preeclampsia and points to an imminent risk of seizures (eclampsia). A patellar reflex graded as 4+ means the nervous system is hyperactive, which is a dangerous progression in this condition. This finding directly guides planning care: initiate or continue seizure-prevention measures such as magnesium sulfate, monitor closely for signs of magnesium toxicity (loss of deep tendon reflexes, drowsiness, or respiratory depression), and be ready to escalate to delivery if the condition worsens.

The other data—blood pressure around 158/80, urine output of 240 ml in four hours, and a respiratory rate of 12—do raise concerns but don’t carry the same immediate implication for seizure prevention. A single elevated BP like 158/80 isn’t necessarily severe hypertension, the urine output is not oliguria by typical thresholds, and a room-air respiratory rate of 12 is within normal limits for an adult. The hyperreflexia thus stands out as the most significant finding for planning urgent care in this scenario.