A nurse is caring for a client who is pregnant. Exhibits Complete the following sentence using the list of options. The provider has admitted the client to an inpatient obstetrics unit and written prescriptions based on the client’s condition. The first action the nurse should take is dropdown followed by dropdown.

The first action the nurse should take is evaluating the fetal heart rate tracing, followed by administering labetalol IV. Rationale for Correct Answers: Evaluating the fetal heart rate tracing first is the priority because the client is at 31 weeks of gestation with severe preeclampsia and reported decreased fetal movement. Fetal assessment is time-sensitive; identifying any signs of fetal distress is critical to prevent hypoxia or other complications. Administering labetalol IV is the next priority to manage the client’s severe hypertension (BP 166/110 mm Hg), which places both mother and fetus at risk for complications such as stroke, placental abruption, or fetal compromise. Rationale for Incorrect options: Administering acetaminophen PO addresses maternal headache but does not prevent immediate maternal or fetal complications, so it is lower priority. Obtaining a 24-hour urine collection, betamethasone, and lactated Ringer’s are important interventions but are secondary to assessing fetal status and stabilizing maternal blood pressure.