A nurse is caring for a 34-year-old female client who is at 34 weeks of gestation in the antepartum unit.

Exhibits

What is the most appropriate action the nurse should take next?

Choice A rationale

Proteinuria and vomiting at 35 weeks gestation are significant symptoms that could indicate preeclampsia, a serious condition that requires immediate assessment and management to prevent complications for both the mother and the baby.

Choice B rationale

Urinary urgency, frequency, and burning at 39 weeks gestation suggest a possible urinary tract infection (UTI), which is concerning but generally not as immediately critical as symptoms suggesting preeclampsia.

Choice C rationale

A fasting blood sugar of 95 mg/dL and a 3-hour glucose of 120 at 30 weeks gestation indicate good control of blood sugar levels, which is not as high-risk as preeclampsia symptoms.

Choice D rationale

A hemoglobin of 12 mg/dL and a potassium level of 3.5 mEq/L at 34 weeks gestation are within normal ranges and do not indicate an immediate high-risk condition compared to the potential for preeclampsia.

• Blood pressure 160/105 mm Hg: This is abnormal as it is significantly elevated, which is a key indicator of preeclampsia.
• Reflexes 3+: This is abnormal and indicates hyperreflexia, often seen in preeclampsia.
• Platelet count 140,000/mm³: This is abnormal since it is on the lower end, suggesting mild thrombocytopenia, common in preeclampsia.
• Temperature 37.2°C: This is normal for a pregnant individual.
• Oxygen saturation 97%: This is normal, indicating adequate oxygenation.