The nurse is caring for a newly admitted in-patient client at 34 weeks gestation with severe preeclampsia. Which healthcare provider prescription is the first priority action for the nurse?

Question

A. Initiate two IV lines with large-bore catheters.

B. Attach the fetal and contraction monitor ASAP.

C. Draw blood for CBC and Complete Metabolic Panel

D. Begin magnesium sulfate bolus.

Answer 1

The priority action is to apply the external fetal and toco (contraction) monitoring system to assess the fetal heart rate response to the preeclampsia. The nurse must remember there are two (or more if a multifetal pregnancy) patients to care for and the only assessment method for the fetal status on admission to the hospital is continuous monitoring of the fetal heart rate. All other answers may be applicable, but would be performed after the fetal monitor is attached.