A nurse is planning care for a client who has terminal cancer and is nearing the end of life. Which of the following interventions should the nurse include?

Rationale for correct choices:

• Placental abruption: Hypertension in pregnancy increases the risk of premature separation of the placenta from the uterine wall. In this case, the elevated BP combined with symptoms like right upper quadrant pain and hyperreflexia suggests a potential complication such as placental abruption.
• Hypertension: A blood pressure of 148/94 mm Hg is above the diagnostic threshold for gestational hypertension. When paired with signs like restlessness, headache, and hyperreflexia, it raises concern for preeclampsia, a known risk factor for placental abruption.

Rationale for incorrect choices:

• Placenta previa: Characterized by painless bleeding in the second or third trimester and associated with abnormal placental placement, not hypertension. The client has no bleeding or ultrasound findings consistent with previa.
• Oligohydramnios: Typically linked to fetal or placental insufficiency or rupture of membranes. No findings in this case suggest low amniotic fluid or related complications.
• Spontaneous abortion: This term applies before 20 weeks’ gestation. The client is 30 weeks pregnant with no signs of fetal demise or expulsion, so this condition does not apply.
• Chorioamnionitis: Requires signs of infection such as fever, uterine tenderness, or foul-smelling discharge. The client is afebrile and has clear lung sounds, making infection unlikely.
• Temperature: The recorded temperature is within normal range (37.4°C), so it does not suggest infection or another abnormality requiring urgent follow-up.
• Vomiting: Common in pregnancy and non-specific unless persistent or linked with abnormal labs. Here, it appears as an isolated symptom and does not directly imply risk of abruption.
• Hyperreflexia: While a sign of preeclampsia, it is secondary to hypertension. It supports the presence of a hypertensive disorder but is not the primary cause of abruption.
• Fundal measurement: A fundal height of 29 cm is normal for 30 weeks’ gestation and does not indicate fetal growth restriction or excess fluid that might signal a complication.

Rationale for correct choices:

• Apply oxygen via nasal cannula: The client is experiencing signs of decreased oxygenation (SpO₂ 92%), shallow respirations, and lethargy, which may indicate central nervous system depression from magnesium sulfate. Administering oxygen improves tissue perfusion and is a priority for maternal and fetal well-being.
• Calcium gluconate: Magnesium sulfate toxicity presents with depressed deep tendon reflexes, lethargy, and respiratory depression. Since the client's DTRs have decreased from 3+ to 1+ and respirations are now shallow, calcium gluconate should be prepared as the antidote to reverse toxicity promptly.

Rationale for incorrect choices:

• Reduce fluid intake: Although the client has reduced urine output and elevated creatinine and BUN levels, there is no indication of fluid overload. Reducing fluids does not address the immediate concern of hypoxia or magnesium toxicity, which are more urgent.
• Discontinue IV infusion: The IV is essential for delivering antihypertensive medications and magnesium sulfate. Discontinuing it would delay critical treatment and worsen the client’s condition. Adjustments, if needed, should follow provider orders after assessment, not be the nurse's initial independent action.
• Hydralazine: Hydralazine is appropriate for severe hypertension but is not the most urgent need when magnesium toxicity is suspected. Managing respiratory compromise and preparing the antidote takes precedence over blood pressure control in this case.
• Nifedipine: Nifedipine was already prescribed and may be administered for ongoing hypertension management. However, it is not used to treat magnesium sulfate toxicity and does not reverse respiratory depression. Thus, while important, it is not the immediate medication to prepare in this scenario.