A nurse is caring for a client who is 6 hours postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse?

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.

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.