A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol, a synthetic prostaglandin E drug.
How should the nurse respond?

Choice A rationale: A blood pressure of 170/98 mm Hg is significantly elevated and concerning during pregnancy. This may indicate preeclampsia, which requires immediate intervention to prevent complications for both the mother and the fetus.

Choice B rationale: A pain rating of 5 out of 10 with each contraction is common during labor and does not necessarily require intervention unless the pain is unmanageable or the client requests additional pain relief measures.

Choice C rationale: Variable decelerations lasting 20 seconds can indicate cord compression or other issues affecting fetal oxygenation. Continuous monitoring and possible interventions are required to ensure fetal well-being.

Choice D rationale: A fetal heart rate of 142 beats/minute with accelerations is a reassuring sign of fetal well-being. No immediate intervention is needed for this finding.

Choice E rationale: Absent deep tendon reflexes are a concerning finding, especially with the administration of magnesium sulfate. This can indicate magnesium toxicity, which requires prompt intervention to adjust the medication dosage and prevent adverse effects.

Choice F rationale: A temperature of 98.6° F (37° C) is within normal limits and does not require intervention.

Choice A rationale

Assessing the fetal heart rate and client's contraction pattern is the highest priority when a large amount of bright red vaginal bleeding occurs. It is crucial to evaluate fetal well-being and the progression of labor to determine any immediate interventions needed to ensure the safety of both the mother and fetus.

Choice B rationale

Confirming Rh and Coombs status for Rho(D) immunoglobulin administration is important for Rh-negative mothers, but it is not the immediate priority in the presence of significant vaginal bleeding. Ensuring fetal and maternal stability takes precedence over Rh status confirmation.

Choice C rationale

Determining fetal position by performing Leopold maneuvers is not the highest priority when there is significant vaginal bleeding. While fetal position is relevant, immediate assessment of fetal heart rate and maternal contraction pattern is more critical for evaluating the urgency of the situation.

Choice D rationale

Performing a sterile vaginal examination to determine dilation is contraindicated in the presence of vaginal bleeding, as it can exacerbate the situation and lead to further complications. Immediate assessment of fetal well-being and maternal condition is more crucial before considering any internal examination. .