The home health nurse is assessing a 17-year-old pregnant client at 34 weeks of gestation who has been diagnosed with preeclampsia. Upon assessment, the nurse finds that the client has gained 2 pounds in the past week and her blood pressure is 144/92 mmHg. Which assessment finding would require further action by the nurse?

Kangaroo care is skin-to-skin contact between a newborn and parent(s) that helps regulate the infant's temperature, respiratory and heart rates, and enhances parent-infant bonding.

It is recommended for all infants, regardless of their gestational age or health status, and has been found to improve outcomes for premature and low-birth-weight infants. Kangaroo care is not specifically designed to address motor and CNS impairments, nor is it adopted from classical British nursing traditions. While it may help prepare infants for breastfeeding, this is not the primary goal of the intervention.

Fetal well-being during labor is assessed by the response of the fetal heart rate (FHR) to uterine contractions (UCs). During labor, the fetal heart rate is monitored to assess the well-being of the fetus. The fetal heart rate should increase in response to fetal movement and contractions, which indicates that the fetus is receiving adequate oxygenation and blood flow. This response is called an "acceleration" in the FHR. However, accelerations alone are not enough to assess fetal well-being during labor. It is the combination of the FHR pattern with the uterine contractions pattern that provides the most information.

In addition to the FHR response to UCs, other factors that may be used to assess fetal well-being during labor include fetal scalp blood sampling, fetal pulse oximetry, and fetal ultrasound. Maternal pain control may help to decrease maternal stress and anxiety during labor, but it is not directly related to fetal well-being. An FHR above 110 beats/min is within the normal range for a fetal baseline heart rate, but it is not enough to assess fetal well-being during labor.