The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?

Insert a Foley catheter with a urimeter to monitor hourly output

Have calcium gluconate immediately available

Provide a quiet environment with subdued lighting.

Assess deep tendon reflexes (DTRS) every 4 hours.