A nurse is caring for a client who is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes. Which of the following actions should the nurse take first?

Choice A Reason:
Tocolytic therapy is not indicated for a client with a post-term pregnancy. Tocolytics are medications used to suppress premature labor, and a pregnancy at 42 weeks is considered post-term, not preterm.

Choice B Reason:
Braxton-Hicks contractions are normal occurrences during pregnancy and do not indicate preterm labor. They are often referred to as "false labor" because they do not lead to cervical dilation or effacement. Therefore, tocolytic therapy is not necessary.

Choice C Reason:
Administering tocolytic therapy in the case of fetal death is not appropriate. Tocolytics are used to delay preterm labor to allow for fetal maturation or to prolong pregnancy to administer corticosteroids for fetal lung development, which is not applicable in this scenario.

Choice D Reason:
Tocolytic therapy is appropriate for a client experiencing preterm labor at 26 weeks of gestation. The goal of tocolytic therapy is to delay delivery to allow for the administration of corticosteroids to accelerate fetal lung maturity or to transfer the client to a facility equipped for premature infants.

Choice a reason:
Elevated blood pressure is a primary indicator for preeclampsia, which is a condition characterized by hypertension and often proteinuria after 20 weeks of gestation. The criteria for hypertension in pregnancy are a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher on two occasions at least 4 hours apart. If a pregnant client presents with elevated blood pressure, it is crucial for the nurse to initiate further evaluation for preeclampsia, as this condition can lead to serious complications for both the mother and the fetus.

Choice b reason:
Joint pain is not a typical sign of preeclampsia. While joint pain can be a symptom experienced during pregnancy due to various physiological changes, it is not specifically associated with preeclampsia and does not warrant further evaluation for this disorder on its own.

Choice c reason:
Vaginal discharge during pregnancy is common and can vary in consistency and amount. It is not a specific indicator of preeclampsia unless accompanied by other symptoms such as elevated blood pressure or proteinuria. Normal vaginal discharge is usually clear or milky white and does not indicate the need for preeclampsia evaluation.

Choice d reason:
Increased urine output is not typically associated with preeclampsia. In fact, preeclampsia can sometimes lead to reduced urine output due to kidney impairment. If a client has increased urine output, it may be due to other factors such as increased fluid intake or gestational diabetes.