A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation. Exhibits Select the 5 findings that require follow-up by the nurse.

A. Blood pressure: An elevated blood pressure of 148/94 mm Hg in a 30-week gestation client indicates potential preeclampsia. This requires follow-up, especially since it is accompanied by other preeclampsia symptoms such as headache and edema. Prompt assessment is essential to prevent progression to severe disease. B. Respiratory assessment: The client’s respiratory rate is 20/min, even and non-labored, with clear breath sounds and 95% oxygen saturation. These are all within normal limits and do not indicate respiratory distress or compromise, so no immediate follow-up is necessary for this system. C. Lower extremity assessment: 1+ dependent edema, though mild, can be an early sign of preeclampsia, especially when associated with elevated blood pressure and weight gain. This symptom requires monitoring for progression and possible systemic involvement. D. Weight assessment: The client gained 0.68 kg (1.5 lb) in a week, which is above the normal range during the third trimester and may represent fluid retention. Coupled with hypertension and edema, it supports the suspicion of preeclampsia and warrants follow-up. E. Fetal heart tracing: A fetal heart rate of 140/min is within the normal range of 110–160 bpm and shows no signs of distress. No immediate intervention is needed for fetal status at this time based on the tracing. F. Nausea: Although nausea can be common in pregnancy, when it appears with headache and right upper quadrant pain, it may be part of the symptom complex for preeclampsia or HELLP syndrome. This combination should be followed up with further evaluation. G. Fundal height: A fundal height of 29 cm at 30 weeks is within acceptable variation (±2 cm of gestational age), indicating appropriate fetal growth. This finding does not require follow-up at this time. H. DTR: 3+ deep tendon reflexes suggest hyperreflexia, which is a neurological sign that can precede seizures in preeclampsia. When seen alongside elevated blood pressure and other systemic symptoms, it requires urgent follow-up to prevent maternal complications.