A nurse is assisting with the care of a client who is in labor. Immediately after the delivery of a newborn, which of the following actions should the nurse take first?

Choice A rationale:

The nurse does not need to report the blood pressure finding. While blood pressure is an essential vital sign to monitor during pregnancy, the scenario does not indicate any abnormalities or concerning values in the client's blood pressure. Therefore, there is no immediate cause for reporting this finding.

Choice B rationale:

The nurse should report cerebral manifestations to the provider. The client's complaint of a more severe headache, rated at 5 on a 0 to 10 pain scale, along with feeling dizzy when getting up from the examination table, may indicate potential neurological symptoms. These could be signs of conditions like preeclampsia, which is a serious pregnancy complication characterized by high blood pressure and signs of damage to other organ systems, including the brain.

Choice C rationale:

The nurse should also report fetal heart rate findings to the provider. The client reports occasional contractions and positive fetal movement, but there is no mention of fetal heart rate in the nurse's notes. Monitoring the fetal heart rate is crucial during prenatal care, as changes in fetal heart rate could indicate fetal distress or other complications.

Choice D rationale:

The nurse does not need to report respiratory rate findings. There is no indication in the nurse's notes of any respiratory issues or complaints from the client, making this finding less relevant to the current situation.

Choice E rationale:

The nurse does not need to report deep tendon reflexes in this context. Deep tendon reflexes are not typically a priority assessment during routine prenatal care unless there are specific concerns or indications of neurological issues.

Choice F rationale:

The nurse does not need to report gastrointestinal assessment findings based on the information provided in the scenario. While the client reports "heartburn,”. there are no other gastrointestinal symptoms or indications of acute gastrointestinal issues requiring immediate reporting.

Choice A rationale:

Hypotension is not an expected finding in a client with severe preeclampsia. In preeclampsia, the client typically experiences hypertension (high blood pressure) rather than hypotension (low blood pressure). Hypotension may be concerning as it could indicate inadequate perfusion to vital organs.

Choice B rationale:

Headache is an expected finding in a client with severe preeclampsia. Headaches are a common symptom of preeclampsia and are often described as persistent and severe. They can result from increased blood pressure and possibly cerebral oedema.

Choice C rationale:

Tachycardia is not an expected finding in a client with severe preeclampsia. Tachycardia refers to an abnormally fast heart rate, but in preeclampsia, bradycardia (abnormally slow heart rate) or a normal heart rate is more typical. Tachycardia could indicate other underlying issues.

Choice D rationale:

Polyuria is not an expected finding in a client with severe preeclampsia. Polyuria is characterized by excessive urination, and in preeclampsia, the opposite may occur due to decreased kidney perfusion, resulting in oliguria (reduced urine output).