A primigravida client at 36-weeks gestation is admitted to the labor and delivery unit because her membranes ruptured 30 minutes ago. Initial assessment indicates a 2 cm cervical dilatation, 50% effaced, -2 station, vertex presentation, greenish-colored amniotic fluid, and contractions occurring every 3 to 5 minutes, with a decrease in fetal heart rate after the last four contraction peaks. Which action should the nurse implement first?

A. Swollen hands can indicate edema, which is a common sign of preeclampsia. Swelling, especially in the hands, face, or feet, can be due to elevated blood pressure and should be reported to the healthcare provider.

B. Headaches are a concerning symptom in preeclampsia, especially when they are persistent or severe. This is often due to high blood pressure and requires medical evaluation to prevent complications like eclampsia or stroke.

C. Blurred vision is a serious indicator of preeclampsia as it reflects possible neurological involvement or increased blood pressure, which can affect blood flow to the brain and eyes. This is an urgent symptom that needs prompt medical attention.

D. Lack of appetite is not a common or specific symptom of preeclampsia. It may be present in other conditions, but it is not a key indicator of preeclampsia.

E. Chills and fever are typically associated with infections, not preeclampsia. These symptoms do not indicate the presence of preeclampsia and are unrelated to hypertensive disorders of pregnancy.

F. Urinary frequency is more commonly related to pregnancy in general due to the growing uterus pressing on the bladder. It is not specifically associated with preeclampsia. In preeclampsia, a decrease in urine output may be more concerning as it can signal kidney involvement.

A. Demonstrating how to palpate the popliteal pulse is not a suitable alternative for measuring blood pressure when the client cannot be measured in the arms or legs. Palpating peripheral pulses does not provide accurate blood pressure measurements.

B. Advising the UAP to document the last blood pressure obtained is insufficient because it does not address the need for current blood pressure monitoring. Documentation of past
measurements does not provide real-time information about the client's hemodynamic status.

C. Estimating the blood pressure by assessing the pulse volume of the client's radial pulses is a reasonable alternative when traditional blood pressure measurement sites are inaccessible. Although not as accurate as traditional methods, assessing the strength of peripheral pulses can provide valuable information about perfusion and blood pressure status.

D. Documenting why the blood pressure cannot be accurately measured is important for record- keeping but does not address the need for ongoing blood pressure monitoring or provide an alternative method for assessment.