A nurse in a prenatal clinic is completing a skin assessment of a client who is in the second trimester. Which of the following findings should the nurse expect? (Select all that apply.)

Explanation:

A. Assess maternal blood glucose:

While assessing blood glucose levels is important in clients receiving magnesium sulfate due to its potential effects on blood sugar, it is not the priority action in this scenario. The client's respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity, which can lead to respiratory depression and neuromuscular effects. Therefore, the immediate concern is addressing the magnesium toxicity rather than assessing blood glucose levels.

B. Place the client in Trendelenburg position:

Placing the client in Trendelenburg position is not indicated for magnesium toxicity. The Trendelenburg position involves placing the client in a supine position with the legs elevated higher than the head. While this position may be used in some situations (e.g., hypotension), it is not appropriate for treating magnesium toxicity, respiratory depression, or absent deep-tendon reflexes. Placing the client in Trendelenburg position may worsen respiratory function and is not recommended in this case.

C. Prepare for an emergency cesarean birth:

While severe preeclampsia or eclampsia may necessitate emergency cesarean birth in some cases, it is not the immediate action needed for a client experiencing respiratory depression and absent deep-tendon reflexes due to magnesium sulfate toxicity. Cesarean birth is not the appropriate response to magnesium toxicity and would not address the client's current respiratory and neuromuscular issues. Therefore, preparing for an emergency cesarean birth is not the correct action in this scenario.

D. Discontinue the medication infusion:

This is the correct action to take. A respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity. Magnesium sulfate, while effective in preventing seizures in preeclampsia, can lead to respiratory depression and affect neuromuscular function at toxic levels. Discontinuing the medication infusion is crucial to prevent further magnesium toxicity and adverse effects on the client's respiratory and neuromuscular status. It is the immediate and priority action needed to address the client's current condition.

Explanation:

A. "This will occur between the fourth and fifth months of pregnancy."

This response is accurate and aligns with the typical timeframe for quickening, which is the first perception of fetal movements by the pregnant person. Quickening commonly occurs between the 16th and 20th week of pregnancy, corresponding to the fourth and fifth months. However, it's essential to note that the exact timing can vary from person to person and pregnancy to pregnancy.

B. "This will happen by the end of the first trimester of pregnancy."

This response is not entirely accurate. Quickening typically occurs later than the end of the first trimester. While some women, particularly those who have been pregnant before, may feel fetal movements toward the end of the first trimester, it's more common to experience quickening during the second trimester.

C. "This will happen once the uterus begins to rise out of the pelvis."

This response is not directly related to quickening. The rising of the uterus (fundus) out of the pelvic cavity is a physical change that occurs as the pregnancy progresses, but it doesn't signify the onset of fetal movements (quickening). Quickening is specifically about feeling the baby's movements, not the position of the uterus.

D. “This will occur during the last trimester of pregnancy."

This response is incorrect. Quickening typically occurs much earlier, specifically during the second trimester, around the 16th to 20th week of pregnancy. Waiting until the last trimester to feel fetal movements would be unusual and might prompt further evaluation or discussion with a healthcare provider.