The nurse is continuing to care for the client.

Complete the following sentence by using the list of options.

The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition.

The action the nurse should take first is

_____

followed by

_____

.

Rationale for correct choices

• Evaluating the fetal heart rate tracing: The client is at 31 weeks of gestation with decreased fetal movement, a sign of potential fetal compromise. Assessing the fetal heart rate immediately allows the nurse to determine fetal well-being and identify any signs of distress. Prompt evaluation is critical in high-risk pregnancies, especially with maternal hypertension and preeclampsia, to guide timely interventions.

• Administering antihypertensives: The client’s blood pressure readings (162/112 mm Hg and 166/110 mm Hg) indicate severe hypertension, increasing the risk for maternal complications such as stroke and eclampsia. Administering prescribed antihypertensives after assessing fetal status helps stabilize maternal blood pressure while maintaining fetal perfusion.

Rationale for incorrect choices

• Administering acetaminophen PO: While the client reports a severe headache, acetaminophen only addresses pain symptomatically and does not treat the underlying severe hypertension or fetal risk. Managing maternal blood pressure and assessing fetal status take priority over analgesic administration in this scenario.

• Obtaining 24-hour urine collection: A 24-hour urine collection to measure proteinuria is important for diagnosing preeclampsia severity, but it is not an immediate action. It is time-consuming and does not provide real-time data on maternal or fetal well-being, so it should follow urgent interventions.

• Administering antibiotics: There is no evidence of infection in the client’s assessment or laboratory findings, so antibiotics are not indicated at this time. Initiating antibiotics would not address the acute maternal or fetal risks associated with severe preeclampsia.

• Encouraging ambulation: Encouraging ambulation is inappropriate in a client with severe hypertension and decreased fetal movement because physical activity could exacerbate maternal risk and stress the fetus. Bed rest and monitoring are safer until the client is stabilized.