A client who is at 20-weeks' gestation visits the prenatal clinic for the first time. Assessment reveals temperature of 98.8° F (37.1° C), pulse of 80 beats per minute, blood pressure of 128/80 mm Hg, weight of 142 lb (64.4 kg) (pre-pregnancy weight was 132 lb (59.9 kg), fetal heart rate (FHR) of 140 beats per minute, urine that is negative for protein, and fasting blood glucose level of 92 mg/dL (5.2 mmol/L). What should the nurse do after making these assessments?
Report the findings because the client needs immediate intervention.
Document the results because they are expected at 20-weeks' gestation.
Record the findings in the medical record because they are not within the norm but are not critical.
Prepare the client for an emergency admission because these findings may represent jeopardy to the client and fetus.