A health care provider reports to the labor nurse that a patient is being transferred from the clinic directly to the hospital with possible preeclampsia. What is the nurse's priority action when the patient is admitted?
a. Obtain the patient's weight.
b. Take the patient's vital signs.
c. Start an IV with lactated Ringer's at 75 mL/hr.
d. Ask support persons to leave the birthing room.
ANS: B
The hallmark signs of preeclampsia are hypertension and proteinuria. These parameters must be evaluated first. Obtaining the patient's weight may indicate excess fluid gain, but fluid retention does not occur in all cases of preeclampsia. An IV will be beneficial; however, assessment precedes implementation in this case to obtain baseline data. Promoting a nonstimulating environment can help decrease blood pressure; however, loss of support during this frightening time can increase anxiety in this initial assessment phase and actually increase the patient's blood pressure.
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