Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center.She is lying supine on a backboard, is awake, and denies any complaints.
Her blood pressure is 80/50 mmHg and her heart rate is 130 beats/minute.
Which action should the nurse implement first?

Choice A rationale: A blood pressure of 170/98 mm Hg is significantly elevated and concerning during pregnancy. This may indicate preeclampsia, which requires immediate intervention to prevent complications for both the mother and the fetus.

Choice B rationale: A pain rating of 5 out of 10 with each contraction is common during labor and does not necessarily require intervention unless the pain is unmanageable or the client requests additional pain relief measures.

Choice C rationale: Variable decelerations lasting 20 seconds can indicate cord compression or other issues affecting fetal oxygenation. Continuous monitoring and possible interventions are required to ensure fetal well-being.

Choice D rationale: A fetal heart rate of 142 beats/minute with accelerations is a reassuring sign of fetal well-being. No immediate intervention is needed for this finding.

Choice E rationale: Absent deep tendon reflexes are a concerning finding, especially with the administration of magnesium sulfate. This can indicate magnesium toxicity, which requires prompt intervention to adjust the medication dosage and prevent adverse effects.

Choice F rationale: A temperature of 98.6° F (37° C) is within normal limits and does not require intervention.

Stopping oxygen per cannula after uterine hyperstimulation and subsequent contraction reduction is not appropriate. Oxygen should be continued to ensure fetal oxygenation, particularly after a period of stress caused by frequent contractions. Discontinuing oxygen too soon may compromise fetal well-being.

Choice B rationale

Checking for clonus in both feet is unrelated to the management of uterine contractions post-oxytocin administration. Clonus assessment is used in evaluating neuromuscular function, often in conditions such as preeclampsia, but not for monitoring uterine activity or response to oxytocin.

Choice C rationale

Notifying the nursery about the client's response is important for continuity of care but does not address the immediate need to manage the uterine contractions. The primary focus should be on stabilizing uterine activity before updating other departments.

Choice D rationale

Restarting the oxytocin infusion rate per protocol is the correct intervention after ensuring that the contractions have reduced to a safe frequency and duration. This approach helps to maintain labor progress while minimizing the risk of hyperstimulation and fetal distress. The nurse should follow the hospital's guidelines for oxytocin titration.