A client at 28 weeks gestation is in preterm labor and it is not expected that the fetus will survive after delivery. What should be the nurse’s initial action?

Choice A rationale

While monitoring vital signs is important in a client with eclampsia, it should be done more frequently than every 4 hours due to the risk of seizures and other complications.

Choice B rationale

Keeping an airway at the bedside is crucial for a client with eclampsia. If a seizure occurs, the airway can be used to ensure the client’s airway remains open.

Choice C rationale

Liberal family visitation may not be appropriate for a client with eclampsia who needs a quiet and stress-free environment to prevent triggering seizures.

Choice D rationale

Assessing temperature every hour is not specifically related to the care of a client with eclampsia.

Choice A rationale

Administering oxygen via facemask is a common intervention for variable decelerations, but it is not the first action that should be taken.

Choice B rationale

Changing the client’s position is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.

Choice C rationale

Turning off the oxytocin infusion is another intervention for variable decelerations, but it is not the first action that should be taken.

Choice D rationale

Assessing cervical dilation is not the first action that should be taken in response to variable decelerations.