Difficulty: Medium
Average Score: 89%
Practice
A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6├âÔÇ╣├à ┬ÃF, P 72, R 20, BP 150/100, and her reflexes are 4. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate?
Correct answer
B
Rationale
Elevated blood pressure and hyperreflexia may indicate impending eclampsia, requiring immediate medical evaluation.