A nurse is assessing a client who presents to the labor and delivery unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor?

Rationale:

A. Remove the safety inspection sticker before plugging in the IV pump: The safety inspection sticker confirms that the device has passed required safety checks. It should remain visible to indicate the equipment is safe for use and up to date with biomedical inspections.

B. Ensure that the electric outlet has two prongs for the IV pump: Medical devices like IV pumps should be plugged into grounded three-prong outlets to reduce the risk of electrical shock. Two-prong outlets are not suitable for hospital-grade equipment.

C. Grasp the IV pump cord when unplugging it from the electrical outlet: Pulling on the cord instead of the plug can damage the wiring and increase the risk of electrical hazard or equipment failure. The plug itself should be held when disconnecting from the outlet.

D. Check the cords of the IV pump for fraying: Inspecting cords for damage such as fraying is a critical safety check before use. Damaged cords pose a serious fire and shock risk and should be reported and repaired before using the device.

Rationale for correct choices:

• DTR 2+ bilaterally: This is within the normal range and shows recovery from previous central nervous system depression caused by magnesium sulfate toxicity, which earlier caused a drop to 1+.
• Urine output 40 mL in the last hour: Output is improving from the prior 20 mL/hr, suggesting better renal perfusion and clearance of magnesium. Adequate urine output is critical to prevent accumulation and toxicity.
• Oxygen saturation 95% on 2 L nasal cannula: This value meets the prescribed goal and reflects stabilized respiratory function after earlier shallow breathing. It indicates successful oxygenation support.

Rationale for incorrect choices:

• Temperature 38.3° C (101° F): This is an elevated temperature and may indicate systemic infection or inflammation. It does not support an improvement in condition and warrants monitoring.
• Heart rate 58/min: This is bradycardia and could indicate lingering effects of magnesium toxicity or a vagal response. It does not reflect improvement and needs further assessment.
• Blood pressure 146/96 mm Hg: Although slightly lower than the earlier reading of 170/112 mm Hg, it is still in the hypertensive range and does not signify resolution of preeclampsia or stabilization.