A postpartum patient with a high spinal cord injury has an indwelling urinary catheter placed for a cesarean birth. The patient's face is red and is complaining of a headache. A current blood pressure measurement is 160/120 mmHg. What should the nurse do first?

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In a patient with a high spinal cord injury, the nurse needs to observe for autonomic dysreflexia during pregnancy, labor, and the immediate postpartum period. This is an exaggerated autonomic response to stimuli. Any irritating condition, such as a distended bladder, may initiate the response. Symptoms include severe hypertension, throbbing headache, and flushing of the skin. Immediate action is needed and includes elevating the patient's head to reduce cerebral pressure and locate the irritating stimulus, which is usually a distended bladder. If bladder distention is the cause and a catheter is in place, check to see why it is not draining and then encourage it to drain by unkinking or flushing to allow urine to flow freely again. As soon as the source of irritation is removed, symptoms typically fade quickly. The indwelling catheter does not need to be removed. Massaging the lower back will not help the symptoms. Lowering the head of the bed could cause the patient to have worsening symptoms.

A Postpartum Patient with a High Spinal Cord Injury Has