A nurse is reviewing a client's rubella titer of 1:8 at her second prenatal visit.
Which of the following statements by the nurse is appropriate?

1. Administer magnesium sulfate bolus: Anticipated. Magnesium sulfate is the drug of choice to prevent seizures in severe preeclampsia or eclampsia. The client shows signs of severe preeclampsia (hypertension, headache, visual disturbances, hyperreflexia, clonus, epigastric pain), so a magnesium sulfate bolus is appropriate to reduce CNS irritability and prevent eclamptic seizures.
2. Insert an indwelling urinary catheter: Anticipated. Monitoring urine output is essential in hypertensive disorders of pregnancy to assess kidney function and fluid balance. The client’s urine output (25–55 mL/hr) is borderline low (normal >30 mL/hr), so catheter insertion allows accurate measurement.
3. Initiate intravenous (IV) fluids: Contraindicated. In preeclampsia, patients often have intravascular volume depletion with risk of pulmonary edema due to increased capillary permeability. IV fluids should be carefully restricted to avoid fluid overload, so routine IV fluid initiation is contraindicated unless hypovolemia or dehydration is confirmed.
4. Administer nifedipine 30 mg intermittent IV bolus: Contraindicated. Nifedipine, a calcium channel blocker, is given orally for hypertension in pregnancy, but intermittent IV bolus administration is not recommended because it can cause abrupt hypotension and fetal distress.
5. Begin intermittent electronic fetal monitoring: Anticipated. Continuous or intermittent fetal monitoring is critical for detecting fetal distress, especially in high-risk pregnancies with maternal hypertension and irregular contractions, ensuring timely intervention if needed.

Choice A rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity, often used in labor inductions complicated by preeclampsia or gestational hypertension. Having it readily available ensures prompt treatment of symptoms like respiratory depression or cardiac arrhythmias caused by magnesium overdose. This safety measure is critical because oxytocin use can increase uterine contractions and magnesium sulfate use requires close monitoring to prevent toxicity.

Choice B rationale: Obtaining the client’s heart rate prior to initiating oxytocin is essential to establish a baseline and monitor for tachycardia or bradycardia, which may affect maternal and fetal safety. Oxytocin can cause cardiovascular changes, including hypertension or arrhythmias, especially in clients with gestational hypertension. Continuous maternal cardiac assessment helps detect adverse effects early and adjust treatment accordingly.

Choice C rationale: Evaluating platelet count before induction is important in clients with gestational hypertension due to the risk of HELLP syndrome, which involves thrombocytopenia. Normal platelet levels range from 150,000 to 400,000/mm³; low levels increase bleeding risk during labor and delivery. Knowing platelet status guides safe management decisions, including anesthesia options and readiness for potential hemorrhagic complications.

Choice D rationale: Assessing for aspirin sensitivity is crucial because aspirin is often used in pregnancy for preeclampsia prevention. Aspirin hypersensitivity can lead to allergic reactions or exacerbation of asthma. Since the client has gestational hypertension, determining aspirin tolerance before administering medications is necessary to prevent adverse drug reactions and ensure safe pharmacologic management.

Choice E rationale: Reviewing the client’s history for heart disease documentation is vital as gestational hypertension increases cardiovascular risk. Preexisting heart conditions can complicate labor induction and oxytocin administration due to possible cardiac overload or arrhythmias. A comprehensive cardiac history ensures appropriate monitoring and interventions to prevent maternal and fetal complications during labor.