A nurse is reviewing the electronic health record of a client who has severe preeclampsia and is being induced with oxytocin.

Which of the following findings should the nurse report to the provider immediately?

“I will resume my normal activities as soon as possible.” This statement indicates a need for further teaching because a woman who had severe pre-eclampsia should rest more often and avoid strenuous activities until her blood pressure is normal and stable.She should also follow up with her doctor regularly and monitor her blood pressure at home.

Choice A is wrong because it is important to monitor blood pressure at home for a few weeks after having pre-eclampsia.

This can help detect any signs of worsening hypertension or organ damage.

Choice B is wrong because it is advisable to call the doctor if there are any headaches or vision changes, as these could be signs of brain injury or eclampsia.

Eclampsia is a serious complication of pre-eclampsia that causes seizures.

Choice C is wrong because some over-the-counter pain medications, such as ibuprofen, can increase blood pressure and should be avoided by women with pre-eclampsia.However, acetaminophen (Tylenol) is usually safe to take for mild pain relief.

Normal ranges for blood pressure during pregnancy are less than 140/90 mmHg.Normal ranges for protein in urine during pregnancy are less than 300 mg in 24 hours.

Turn the client to the side.This is because turning the client to the side will prevent aspiration of secretions or vomitus and maintain a patent airway during a seizure.

This is the most important and immediate action to take for a client with eclampsia who is having a tonic-clonic seizure.

Choice A is wrong because administering oxygen via face mask is not the first priority and may not be feasible during a seizure.Oxygen therapy may be indicated after the seizure to improve oxygenation and fetal well-being.

Choice C is wrong because inserting an oral airway is contraindicated during a seizure as it may cause injury to the oral mucosa or trigger a gag reflex.An oral airway may be used after the seizure if the client is unconscious and has a compromised airway.

Choice D is wrong because giving a loading dose of magnesium sulfate is not the first action to take, although it is an important intervention to prevent further seizures and lower blood pressure in eclampsia.Magnesium sulfate should be administered intravenously after securing the airway and ensuring adequate ventilation.