A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take?

A. A history of gastroesophageal reflux disease: GERD increases the likelihood of gastric contents refluxing into the esophagus and potentially being aspirated into the lungs. Clients receiving enteral feedings with impaired lower esophageal sphincter function are at higher risk for aspiration pneumonia, making this a significant risk factor.

B. Receiving a high-osmolarity formula: High-osmolarity formulas may cause gastrointestinal discomfort, diarrhea, or delayed gastric emptying, but they do not directly increase aspiration risk if proper feeding techniques and positioning are used.

C. A residual of 65 mL 1-hr postprandial: A small gastric residual of 65 mL is generally considered within acceptable limits and does not significantly increase aspiration risk. High residuals (e.g., >250 mL) are more concerning.

D. Sitting in high-Fowler's position during the feeding: Maintaining a high-Fowler’s position (60–90°) during enteral feeding reduces aspiration risk by promoting gastric emptying and minimizing reflux. This positioning is protective rather than a risk factor.

A. Assess DTR: Hyperreflexia (3+ DTRs) is an early neurological sign of preeclampsia and potential progression to eclampsia. Monitoring deep tendon reflexes helps detect worsening central nervous system irritability and guides timely intervention.

B. Encourage bed rest: Bed rest can reduce maternal blood pressure and improve uteroplacental perfusion in clients with preeclampsia. While strict bed rest is debated, modified rest in a low-stimulation environment is appropriate for symptom management and safety.

C. Prepare for amniocentesis: Amniocentesis is not indicated in this scenario. The client’s presentation suggests preeclampsia with severe features, and amniocentesis does not address maternal hypertension, organ dysfunction, or fetal compromise.

D. Monitor blood pressure: Frequent blood pressure monitoring is essential for detecting rapid increases or hypertensive crises in preeclampsia. Early detection allows prompt administration of antihypertensives and prevents complications such as stroke or placental abruption.

E. Check urinary output: Oliguria can indicate worsening renal involvement in preeclampsia. Monitoring urinary output is crucial to assess renal function, fluid balance, and the severity of proteinuria.

F. Initiate contact precautions: Preeclampsia is not an infectious condition; contact precautions are unnecessary. Standard precautions are sufficient unless another infectious risk is present.

G. Apply internal fetal monitor: Internal fetal monitoring is invasive and only indicated when external monitoring is inadequate or continuous detailed monitoring is needed. Currently, fetal heart rate is being assessed externally and is stable.

H. Decrease lighting in the client's room: Reducing environmental stimuli can help minimize neurological irritability and agitation in clients with severe preeclampsia, lowering the risk of seizures and promoting maternal comfort.