A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4°C (97.6°F). Which of the following is the priority nursing action?

Choice A reason:
Continuous fetal monitoring is a standard order for clients with severe preeclampsia. It allows healthcare providers to assess the baby's heart rate pattern, which can indicate how well the baby is tolerating the intrauterine environment. This is particularly important in cases of severe preeclampsia, where there is a risk of fetal distress.

Choice B reason:
Obtaining a daily weight is also a standard practice for clients with severe preeclampsia. Weight gain can be an indicator of worsening preeclampsia due to fluid retention and should be monitored closely. Sudden weight gain can signify increased fluid retention, which may require medical intervention.

Choice C reason:
Assessing deep tendon reflexes every hour is appropriate for clients with severe preeclampsia. Hyperreflexia can be a sign of worsening preeclampsia and impending eclampsia. Frequent monitoring allows for early detection of changes in reflexes, which can be critical in managing the condition.

Choice D reason:
Ambulating twice daily would require clarification because clients with severe preeclampsia are typically advised to have bed rest to lower blood pressure and reduce the risk of complications. Ambulation could increase the risk of hypertensive crisis or other complications, so this order seems contrary to standard management practices for severe preeclampsia.

In the scenario provided, the Apgar score is calculated as follows:

- Appearance (skin color): The newborn has a pink trunk and head with bluish hands and feet, which scores 1 point.
- Pulse (heart rate): The heart rate is 130/min, which is above 100/min, so this scores 2 points.
- Grimace response (reflex irritability): The newborn cries in response to suctioning, which scores 2 points.
- Activity (muscle tone): The newborn has flexed extremities, which scores 2 points.
- Respiration (breathing effort): The cry is weak and slow, which scores 1 point.

Adding these up gives us a total Apgar score of 8 out of a possible 10 points.

Appearance (skin color): Normally, a score of 2 is given if the entire body is pink, 1 for pink body but blue extremities, and 0 if the whole body is pale or blue. The newborn's pink trunk and head with bluish hands and feet warrant a score of 1.

Pulse (heart rate): A score of 2 is given for a heart rate above 100/min, 1 for below 100/min, and 0 if there is no heartbeat. The newborn's heart rate of 130/min earns a score of 2.

Grimace response (reflex irritability): A score of 2 is given for a sneeze, cough, or vigorous cry, 1 for a grimace or feeble cry upon stimulation, and 0 for no response. The newborn's crying in response to suctioning gets a score of 2.

Activity (muscle tone): A score of 2 is given for active motion, 1 for some muscle tone and flexion of extremities, and 0 for limpness. The newborn's flexed extremities give a score of 2.

Respiration (breathing effort): A score of 2 is given for a good, strong cry, 1 for slow or irregular breathing, and 0 for no breathing. The newborn's weak and slow cry results in a score of 1.

The Apgar score helps the healthcare team decide if the newborn needs immediate medical care. A score of 7-10 is generally normal, 4-6 fairly low, and 3 and below critically low. An Apgar score of 8 indicates that the newborn is in good health but may need some medical attention, likely due to the weak and slow cry.