The nurse continues to care for the client who is at 30 weeks of gestation. 

Exhibits

Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

A. Contact precautions are not indicated based on the assessment findings provided.  Preeclampsia is primarily a hypertensive disorder of pregnancy characterized by systemic  manifestations such as elevated blood pressure, proteinuria, and multiorgan involvement.  It is not transmitted through direct contact, so contact precautions are unnecessary. 

B. The client is exhibiting signs and symptoms consistent with preeclampsia, including  right upper abdominal pain, headache, nausea, vomiting, facial edema, weight gain, and  elevated blood pressure. Monitoring urinary output is essential for assessing renal  function and detecting oliguria, which is a potential complication of preeclampsia.

C. Reducing stimuli, such as bright lights and loud noises, can lower the risk of seizures in clients with preeclampsia.

D. The client's blood pressure readings are elevated, indicating hypertension, which is a  hallmark sign of preeclampsia. Monitoring blood pressure regularly is crucial for  assessing the severity of hypertension and guiding management. 

E. Amniocentesis is not indicated based on the assessment findings provided.  Amniocentesis is a diagnostic procedure typically performed to obtain amniotic fluid for  various purposes, such as fetal lung maturity assessment or genetic testing. In the context  of preeclampsia, it is not a standard intervention. 

F. Internal fetal monitoring is typically used during labor to provide a more accurate reading of the baby's heart rate. It involves guiding a thin wire through the cervix and attaching it to the baby's scalp. At 30 weeks gestation, internal monitoring would not be standard practice as it is invasive and labor has not yet commenced.

G. Deep tendon reflexes (DTRs) are assessed to monitor for signs of neurological  involvement in preeclampsia. Hyperreflexia, as indicated by a 3+ DTR bilaterally, is a  characteristic finding in severe preeclampsia and may indicate central nervous system  irritability. 

H. Bed rest is often recommended for clients with preeclampsia to reduce physical  activity and minimize the risk of complications such as eclampsia or stroke. It can help  lower blood pressure and reduce the risk of placental abruption.