The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate, it is noted the client developed significantly elevated...

The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate, it is noted the client developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below the prescribed rate. In addition to adjusting the infusion rate and notifying the MD, which of the following is the most important action by the nurse?

1. Complete an incident report.

2. Discuss the matter with the nurse the next time she works.

3. Ask the charge nurse if an incident report is necessary.

4. Evaluate the client's BP for 4 hours before making a decision.