The LPN is assisting the RN in monitoring a client who is G2P1 at 39 weeks gestation (EDD confirmed), admitted in early labor. Baseline vital signs on admission were BP 118/72 mmHg, pulse 82 beats/min, respirations 18 breaths/min, temperature 37.1°C. During the current assessment, the LPN obtains BP 158/102 mmHg, notes 2+ pitting edema of the hands and face, fetal heart rate 140 beats/min with moderate variability, fundal height consistent with dates, and contractions every 4 minutes. The client reports a severe frontal headache and blurred vision that started 20 minutes ago. What should the LPN do first?
- Report the elevated blood pressure, edema, headache, and visual changes to the RN immediately.
- Finish reinforcing the teaching plan about breathing techniques before addressing the vital signs.
- Continue routine comfort measures and document the findings for the next scheduled check.
- Tell the client that headaches and mild vision changes are common in late labor.