A nurse is caring for a patient who has been admitted to the labor and delivery unit.
After reviewing the patient’s vital signs and nurse’s notes, what condition is the patient most likely experiencing, what actions should the nurse take to address that condition, and what parameters should the nurse monitor to assess the patient’s progress?

The correct answers are A. Start breastfeeding with the nipple that is less sore, B. Change the infant’s position on the nipples, and C. Apply breast milk to the nipples before each feeding.

Choice A rationale:

Starting breastfeeding with the nipple that is less sore can help reduce discomfort. The baby tends to suck more vigorously at the beginning of a feeding, so starting with the less sore nipple can minimize pain.

Choice B rationale:

Changing the infant’s position on the nipples can help distribute the pressure more evenly and prevent further irritation of sore areas. Different positions can also help ensure a better latch.

Choice C rationale:

Applying breast milk to the nipples before each feeding can soothe and promote healing of sore nipples. Breast milk has natural antibacterial properties and can help keep the nipples moisturized.

Choice D rationale:

Massaging the breasts and nipples prior to feeding is not typically recommended for reducing nipple soreness. It can potentially cause more irritation and discomfort.

Choice E rationale:

Placing breast pads inside the nursing bra can help absorb leakage and keep the nipples dry, but it does not directly reduce soreness during breastfeeding. It is more of a preventive measure to maintain hygiene.

The correct answer is choice C: Respiratory rate.

Choice A rationale:

Fetal heart rate (FHR) is an important assessment for clients experiencing preterm labor, but it is not the priority assessment when administering magnesium sulfate. FHR monitoring is crucial to ensure fetal well-being but is not directly related to the potential adverse effects of magnesium sulfate.

Choice B rationale:

Temperature is an essential assessment parameter, but it is not the priority in this case. Magnesium sulfate administration can cause adverse effects, particularly on the respiratory system, which should be closely monitored.

Choice C rationale:

Respiratory rate is the correct choice because respiratory rate is a priority assessment when administering magnesium sulfate. The drug can cause respiratory depression and other respiratory complications, so monitoring the respiratory rate is essential to ensure the client's safety.

Choice D rationale:

Bowel sounds are not a priority assessment for a client receiving magnesium sulfate. While gastrointestinal side effects can occur with magnesium sulfate use, respiratory assessments take precedence.

In conclusion, the priority nursing assessment for a client receiving magnesium sulfate is the respiratory rate due to the potential respiratory complications associated with the drug. Monitoring respiratory function closely can help prevent adverse outcomes and ensure the client's safety during treatment.