A new mother asks the nurse why her infant son has a needle mark on his leg.Which response is best for the nurse to provide this mother?

Choice A rationale

Documenting the vital signs in the medical record is appropriate as the vital signs provided fall within expected ranges for a postpartum client. A temperature of 100.4°F (38°C) can be normal due to dehydration or exertion from labor, and bradycardia (heart rate 58 beats/minute) is common in postpartum women due to increased stroke volume and cardiac output.

Choice B rationale

Assessing the perineum for excessive lochia is important if there are concerns about postpartum hemorrhage, but it is not directly related to the provided vital signs. While lochia should be monitored, the vital signs alone do not indicate excessive bleeding or other complications.

Choice C rationale

Administering acetaminophen for a temperature of 100.4°F (38°C) may not be necessary, as this temperature can be considered within normal limits postpartum. Fever above 100.4°F may warrant medication, but the provided vital signs suggest no immediate need for intervention.

Choice D rationale

Reporting the heart rate to the healthcare provider is unnecessary because bradycardia (heart rate 58 beats/minute) is normal in postpartum women. Increased stroke volume during the postpartum period can result in lower heart rates. The vital signs provided do not indicate a cause for concern.

Condition: Preeclampsia with severe features.

2 actions:

Administer magnesium sulfate as prescribed,

Monitor for signs of magnesium toxicity.

2 parameters:

Urine output of at least 30 mL/hour,

Deep tendon reflexes.

Rationale for correct condition: Preeclampsia with severe features is indicated by the elevated blood pressure of 170/98 mm Hg and the need for magnesium sulfate. The goal is to prevent eclampsia and manage severe preeclampsia symptoms. The variable decelerations noted in the fetal heart rate are consistent with preeclampsia. The client's blood pressure is critically high, requiring immediate intervention. Magnesium sulfate is used to prevent seizures in severe preeclampsia.

Rationale for actions: Administering magnesium sulfate is essential to prevent seizures associated with severe preeclampsia. It stabilizes the client and reduces the risk of eclampsia. Monitoring for signs of magnesium toxicity ensures safe administration. Symptoms like respiratory depression and loss of reflexes indicate toxicity, requiring dose adjustment. Preparing for an emergency cesarean section is not immediately necessary. Placing the client in a supine position can worsen blood pressure. Restricting fluid intake is not a priority without signs of fluid overload.

Rationale for parameters: Monitoring urine output ensures kidney function and fluid balance. Preeclampsia can affect renal function, making this parameter critical. Deep tendon reflexes help assess neurological status and detect magnesium toxicity early. Changes in reflexes guide dosage adjustments. Fetal heart rate variability is important but secondary here. Oxygen saturation is stable and less relevant. Serum magnesium levels above 8 mg/dL indicate toxicity and are not the target.

Rationale for incorrect conditions: Gestational hypertension involves elevated blood pressure without severe features or the need for magnesium sulfate. Placental abruption would present with more severe pain and bleeding. Preterm labor does not align with the focus on hypertension and magnesium sulfate use.