In preparing a gravid client for a triple screen analysis, which action should the nurse take?

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.

Choice A rationale

Documenting the vital signs in the medical record is appropriate as the vital signs provided fall within expected ranges for a postpartum client. A temperature of 100.4°F (38°C) can be normal due to dehydration or exertion from labor, and bradycardia (heart rate 58 beats/minute) is common in postpartum women due to increased stroke volume and cardiac output.

Choice B rationale

Assessing the perineum for excessive lochia is important if there are concerns about postpartum hemorrhage, but it is not directly related to the provided vital signs. While lochia should be monitored, the vital signs alone do not indicate excessive bleeding or other complications.

Choice C rationale

Administering acetaminophen for a temperature of 100.4°F (38°C) may not be necessary, as this temperature can be considered within normal limits postpartum. Fever above 100.4°F may warrant medication, but the provided vital signs suggest no immediate need for intervention.

Choice D rationale

Reporting the heart rate to the healthcare provider is unnecessary because bradycardia (heart rate 58 beats/minute) is normal in postpartum women. Increased stroke volume during the postpartum period can result in lower heart rates. The vital signs provided do not indicate a cause for concern.