A nurse is assisting in the care of a client who is in labor and requires intermittent fetal monitoring.
Which of the following actions should the nurse take?

High blood pressure during pregnancy can indicate preeclampsia, a potentially dangerous condition requiring prompt intervention. Headache is a common symptom associated with preeclampsia and can indicate worsening condition.

1. Addressing blood pressure is crucial to prevent complications such as eclampsia or organ damage.
2. Monitoring the headache is necessary because it may signal increased intracranial pressure or severe hypertension, both of which need immediate attention.
3. Elevated liver enzymes (AST 200 units/L) indicate potential liver involvement, a severe aspect of preeclampsia known as HELLP syndrome.
4. Keeping a close eye on liver enzymes helps in assessing the progression and severity of preeclampsia and potential liver damage.

Heart rate and respiratory rate are within normal ranges, so they are less immediately concerning. Oxygen saturation is also normal, indicating adequate oxygenation. The headache and elevated liver enzymes are more urgent indicators of severe preeclampsia complications.

Choice A rationale

Wearing an underwire bra is not recommended for clients with inverted nipples as it can cause discomfort and restrict milk flow. Proper support without constriction is essential.

Choice B rationale

Placing breast shells in the client's bra helps to draw out inverted nipples by applying gentle pressure, making breastfeeding easier. They also protect the nipples from friction and irritation.

Choice C rationale

Providing plastic-lined breast pads may prevent leakage, but they do not address the issue of inverted nipples. Proper nipple preparation is essential for effective breastfeeding.

Choice D rationale

Applying breast cream regularly might keep the skin hydrated, but it does not help to correct the inversion of the nipples. Mechanical aids like breast shells are more effective.