A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?
Explanation & Rationale
A. Continuous fetal monitoring: Clients with severe preeclampsia require close fetal surveillance due to the risk of uteroplacental insufficiency. Continuous monitoring helps detect fetal distress or decreased variability. It provides critical information for timely intervention. B. Assess deep tendon reflexes every hour: Magnesium sulfate, used for seizure prophylaxis in preeclampsia, can cause toxicity. Hourly DTR assessment helps identify early signs of neuromuscular depression. Monitoring reflexes ensures safe medication titration. It also helps track disease severity progression. C. Obtain a daily weight: Daily weights are essential to evaluate fluid retention, which can indicate worsening preeclampsia. Fluid shifts and edema are common complications that require tracking. Weight changes guide treatment decisions. This is a routine part of preeclampsia management. D. Ambulate twice daily: Severe preeclampsia often warrants limited activity or bed rest to reduce blood pressure fluctuations. Ambulation may increase the risk of complications like seizures or placental abruption. Activity restrictions help stabilize the maternal condition. Safety is prioritized over mobility.