A nurse is caring for a client who is 2 hours postpartum. The nurse notes that the client soaked a perineal pad in 10 minutes, the client's skin color is ashen, and she states she feels weak and lightheaded. After applying oxygen via nonrebreather face mask at 10 L/min, which of the following actions should the nurse take next?

Choice A reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. High blood pressure is a hallmark sign of preeclampsia, and a reading at or above 140/90 mm Hg is considered elevated and may warrant a preeclampsia diagnosis.

Choice B reason:
The presence of 3+ protein in the urine is another indicator consistent with preeclampsia. Proteinuria, or high levels of protein in the urine, is a common symptom of preeclampsia and can indicate kidney involvement.

Choice C reason:
1+ pitting sacral edema is also consistent with preeclampsia. While some swelling is normal during pregnancy, sudden or excessive swelling (edema) can be a sign of preeclampsia, especially when it occurs in the face, hands, or around the eyes.

Choice D reason:
Deep tendon reflexes of +1 are generally considered to be within the normal range. In preeclampsia, hyperreflexia, or increased reflexes, are more common due to heightened nervous system activity, which would be indicated by a score higher than +2². Therefore, a finding of +1 is inconsistent with preeclampsia and may suggest that reflexes are not as heightened as would typically be expected in this condition.

Choice a reason:
An irregular fetal heart rate is not typically associated with a hydatidiform mole because, in many cases of complete molar pregnancy, there is no fetus, and thus no fetal heart rate to assess. In partial molar pregnancies, there may be a fetus with an irregular heart rate, but this is not a definitive sign of a hydatidiform mole.

Choice b reason:
Profuse, clear vaginal discharge is not a common finding in hydatidiform mole. The typical vaginal discharge associated with a molar pregnancy is often described as "grape-like" or "prune juice-like" due to the presence of molar tissue being passed.

Choice c reason:
A rapid decline in hCG levels is not expected in hydatidiform mole; in fact, unusually high levels of hCG are more characteristic of this condition. The abnormal placental tissue in a molar pregnancy tends to produce higher than normal amounts of hCG.

Choice d reason:
Excessive uterine enlargement is a key finding in hydatidiform mole. The uterus often becomes larger than expected for the gestational age because the abnormal placental tissue grows rapidly and takes up more space within the uterus. This can happen within 10 to 16 weeks of gestation and is one of the primary clinical signs that lead to the suspicion of a molar pregnancy.