A nurse is caring for a client who is at 36 weeks of gestation.

Exhibits

For each day 2 finding, click to specify whether the finding indicates that the client's condition has improved, has not changed, or has declined.

Rationale:

A. Headache can be a common side effect of magnesium sulfate but is usually not concerning unless severe or persistent.

B. A fetal heart rate of 158/min is within the normal range for a fetus and is not typically associated with magnesium sulfate administration.

C. Respirations of 16/min are within the normal range and are not typically associated with magnesium sulfate administration.

D. A urinary output of 40 mL in 2 hours is significantly reduced and may indicate magnesium toxicity or impaired renal function, which should be reported to the provider for further

evaluation and management.

Rationale:

A. Obtain a type and crossmatch: While obtaining a type and crossmatch may be necessary in the event of significant hemorrhage, the first action should be to address the potential cause of hypotension, which could be uterine atony.

B. Evaluate the firmness of the uterus: Postpartum hypotension is often caused by uterine atony, so the first action should be to assess the firmness of the uterus and massage it to stimulate contraction if necessary.

C. Administer oxytocin infusion: Oxytocin infusion may be necessary to help contract the uterus and control bleeding, but it should be implemented after assessing uterine firmness.

D. Initiate oxygen therapy by nonrebreather mask: While oxygen therapy may be needed if the client is hypotensive due to hemorrhage, assessing uterine firmness is the priority action to address the potential cause of hypotension.