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.

Rationale: A. Initiate contact precautions: No signs of infection or communicable disease are present, so contact precautions are unnecessary. B. Decrease lighting in the client’s room: The client is restless and later becomes lethargic, suggesting neurological irritability or worsening preeclampsia. Reducing environmental stimuli like lighting can help minimize seizures and agitation. C. Check urinary output: The client’s urine output decreased to 20 mL in one hour, which is concerning for renal impairment often seen in severe preeclampsia. Monitoring output closely helps detect worsening kidney function and fluid balance. D. Prepare for amniocentesis: There is no indication for amniocentesis in this clinical scenario related to preeclampsia or maternal condition. E. Encourage bed rest: Bed rest in the side-lying position improves uteroplacental perfusion and helps control blood pressure, reducing the risk of complications from preeclampsia. F. Monitor blood pressure: Blood pressure is elevated and critical to assess frequently to evaluate disease progression and prevent hypertensive emergencies or seizures. G. Apply internal fetal monitor: The client has no contractions and a stable external fetal heart rate. Internal monitoring is invasive and reserved for active labor or when external monitoring is insufficient. H. Assess DTR: The shift from hyperreflexia (3+) to hyporeflexia (1+) may indicate worsening neurological status or magnesium sulfate toxicity if administered. Continuous monitoring is essential.