The nurse is continuing to assist with the care of the client. Nurses' Notes. 0900: 0930: Client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen. Client also reports urinary frequency and decreased fetal movement. Client is a. gravida 3, para 2 with one preterm birth. Client reports a constant and throbbing headache and rates their pain as a 6 on a scale of 0 to 10. Denies visual disturbances. +3 pitting edema in bilateral lower extremities. Patellar reflex 4+ without the presence of clonus. Client reports occasional nighttime leg cramps. Reports 3 fetal movements within the last 30 min. External fetal monitor applied with a. baseline FHR 140/min with occasional accelerations and moderate variability. No uterine contractions noted. The nurse is assisting with initiating the client's plan of care. Which of thefollowing interventions should the nurse include? Select all that apply.

Choice A rationale: Performing a vaginal examination every 12 hours is not necessary in this case. The client is not in labor and there are no indications of any complications that would require frequent vaginal examinations. Choice B rationale: The client’s symptoms of severe headache, +3 pitting edema in bilateral lower extremities, and a patellar reflex of 4+ without the presence of clonus are indicative of severe preeclampsia. Antihypertensive medications are often used to manage high blood pressure in preeclampsia. Choice C rationale: Betamethasone is a corticosteroid that is given to pregnant women who are at risk of delivering prematurely to help mature the baby’s lungs. Given that the client is at 31 weeks of gestation and has had a previous preterm birth, administering betamethasone would be appropriate. Choice D rationale: A low-stimulation environment can help reduce blood pressure and prevent seizures in clients with preeclampsia. Choice E rationale: Bed rest can help lower blood pressure and improve blood flow to the placenta, which can be beneficial for the baby. Choice F rationale: Monitoring intake and output every hour can help assess kidney function, which can be affected by preeclampsia. Choice G rationale: A 24-hour urine specimen can provide information about protein levels in the urine, which can indicate the severity of preeclampsia. It’s important to note that normal ranges for lab parameters can vary slightly depending on the lab, but generally, protein levels in a 24-hour urine specimen should be less than 300 mg. Pitting edema is usually graded on a scale of 1+ (mild) to 4+ (severe), and a patellar reflex of 4+ is considered hyperactive and may indicate nervous system hyperexcitability seen in severe preeclampsia or eclampsia.