A multigravida client at 31 weeks gestation is admitted with confirmed pre-term labor.
As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?

Choice A rationale

While addressing the client's feelings is important, dismissing the need for blood pressure monitoring is not appropriate nursing practice during pregnancy. Routine blood pressure checks are essential for detecting potential complications.

Choice B rationale

While blood pressure can increase in the second trimester due to physiological changes like increased blood volume, it doesn't invariably increase early in the second trimester, and this statement might cause unnecessary alarm if the client's blood pressure is currently normal.

Choice C rationale

Advanced maternal age (typically over 35) is a risk factor for gestational hypertension, but stating this directly without knowing the client's baseline blood pressure or other risk factors might be alarming and isn't the primary reason for routine monitoring at every prenatal visit.

Choice D rationale

Routine blood pressure monitoring is a standard component of prenatal care for all pregnant clients, regardless of their past medical history or perceived risk. This allows for the early detection of gestational hypertension or preeclampsia, which can develop even in women with previously normal blood pressure. Early detection and management are crucial for maternal and fetal well-being.

Choice A rationale

Supine positioning can compress the vena cava, leading to decreased venous return, reduced cardiac output, and potential maternal hypotension, which can compromise fetal oxygenation. Alternative positions like lateral or semi-recumbent are generally preferred during labor to optimize blood flow.

Choice B rationale

Assessing anesthesia or pain level every 30 minutes is crucial in the active phase of labor to evaluate the effectiveness of pain management interventions and the client's comfort. This frequent monitoring allows for timely adjustments to the pain management plan based on the client's subjective experience and physiological responses.

Choice C rationale

While assessing vaginal bleeding and the fundus is important in the postpartum period to monitor for uterine involution and hemorrhage, it is not the priority during the active phase of labor. The focus during active labor is on maternal and fetal well-being during the labor process itself.

Choice D rationale

Continuous or intermittent oxygen saturation monitoring may be indicated based on the client's condition and fetal heart rate patterns, but it is not a routine assessment every half hour for all clients in active labor. It is typically reserved for situations of suspected maternal hypoxemia or fetal distress.