A nurse is caring for a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110mm Hg. Which of the following actions should the nurse take first?

A. Document an incident report in a client's medical record: Incident reports are essential for internal documentation but should not be placed in the client’s medical record. Including them in the medical record can lead to legal complications. This action addresses individual events rather than contributing to systematic quality improvement efforts.

B. Notify the provider if a client falls: Notifying the provider about a fall is a necessary clinical step to ensure immediate evaluation and care for the client. However, simply informing the provider does not contribute directly to a quality improvement initiative aimed at analyzing and reducing overall fall rates.

C. Assist with the care of a client who has fallen: Providing immediate care after a fall is crucial to ensure client safety and manage injuries. However, assisting after the fall focuses on acute clinical response rather than on proactive measures to identify trends and reduce the incidence of future falls.

D. Collect data about each fall: Collecting data is a fundamental part of quality improvement projects. By systematically gathering information on when, where, and how falls occur, patterns can be identified, leading to the development of targeted interventions aimed at preventing future incidents.

• Placenta previa: Placenta previa occurs later in pregnancy and is characterized by painless bright red vaginal bleeding without abdominal tenderness. The client is only 6 weeks pregnant, and placenta previa is not a concern this early in gestation.
• abruptio placentae: Abruptio placentae involves painful bleeding and a rigid uterus, usually occurring after 20 weeks' gestation. The client’s gestational age and presenting symptoms are more consistent with an early pregnancy complication rather than abruptio placentae.
• ectopic pregnancy: This occurs when a fertilized egg implants outside the uterus. The client’s missed period, positive pregnancy test, right lower quadrant tenderness, and dark red vaginal spotting are classic signs of ectopic pregnancy. Ectopic pregnancy is a life-threatening emergency if rupture occurs, requiring prompt identification and management.
• acute asthma attack: While the client has a history of asthma and slight inspiratory wheezing, her respiratory status is stable with normal oxygen saturation and no signs of acute respiratory distress. Therefore, an asthma attack is not the primary concern.
• pyelonephritis: Pyelonephritis typically presents with fever, chills, flank pain, and urinary symptoms. The client’s presentation of right lower quadrant tenderness and vaginal spotting does not align with the typical findings of pyelonephritis.
• respiratory rate: The client’s respiratory rate is normal at 16/min, indicating stable respiratory function. Respiratory rate does not explain the primary concern related to abdominal pain and vaginal bleeding.
• history of regular menstrual period: While this supports that the client is late in her cycle, it is not the most direct or critical finding pointing toward the diagnosis. The focus should be on current clinical signs like abdominal tenderness.
• temperature: The client’s temperature is within normal range at 37.3°C (99.1°F), making infection less likely and not the primary concern related to her current symptoms.
• right lower quadrant abdominal tenderness: Localized tenderness in the right lower quadrant combined with vaginal spotting strongly suggests an ectopic pregnancy. This is a hallmark finding that supports the diagnosis as the growing embryo can cause irritation, stretching, or rupture of the fallopian tube.
• hyperactive bowel sounds: Hyperactive bowel sounds are nonspecific and can occur due to anxiety, mild gastrointestinal upset, or pain, but they are not diagnostic for ectopic pregnancy. The abdominal tenderness is the more significant finding.