A nurse is caring for a client who is at 37 weeks of gestation and experiences a spontaneous rupture of membranes before labor has begun. Which of the following actions should the nurse take?

Rationale:
A. The client agreed to the procedure voluntarily: By witnessing the signature, the nurse verifies that the client is signing the consent form without coercion, fulfilling the legal requirement that consent is given voluntarily. This does not require the nurse to provide detailed explanations of the procedure.

B. The nurse explained the surgical procedure in detail: The responsibility for explaining the procedure, risks, and benefits lies with the surgeon or provider, not the nurse witnessing the consent. Witnessing only confirms voluntary agreement.

C. The nurse explained the risks and benefits of the surgery: Explaining risks and benefits is the provider’s legal obligation. The nurse’s role is to witness the client’s signature, not to provide detailed medical explanations.

D. The client knows they may no longer refuse the procedure: Clients always retain the right to refuse a procedure, even after signing consent. Witnessing does not override the client’s autonomy or ability to change their mind.

Rationale for Correct Choices

• Evaluating the fetal heart rate tracing: The client presents with severe preeclampsia, as indicated by hypertension (166/110 mm Hg), 3+ proteinuria, and hyperreflexia. The priority is to assess fetal well-being since decreased fetal movement and maternal hypertension can compromise placental perfusion, placing the fetus at risk for hypoxia or distress.

• Administering magnesium sulfate IV: Once fetal assessment confirms stability, magnesium sulfate should be initiated to prevent eclamptic seizures. This medication stabilizes the central nervous system by reducing neuromuscular excitability and cerebral irritation associated with severe preeclampsia.

Rationale for Incorrect Choices

• Administering acetaminophen PO: The client already reported that acetaminophen was ineffective for headache relief. The headache is a sign of severe preeclampsia, not a benign pain complaint, so administering more acetaminophen does not address the underlying pathology.

• Obtaining 24-hour urine collection: While important for confirming the degree of proteinuria, this action is not an immediate priority. Stabilizing maternal and fetal conditions takes precedence over diagnostic collection.

• Inserting an indwelling urinary catheter: The catheter is required for strict intake and output monitoring during magnesium therapy, but it is not performed before ensuring fetal stability and initiating seizure prophylaxis.

• Administering betamethasone IM: Betamethasone promotes fetal lung maturity, which is appropriate in preterm conditions; however, it is not the immediate priority. Seizure prevention and fetal assessment are more urgent interventions at this stage.