A nurse is planning to administer Rh(D) immune globulin to a client who is postpartum.
Which of the following actions should the nurse take?

Choice A rationale

Agitation is not a common adverse effect of magnesium sulfate therapy. It is more likely to be caused by other factors.

Choice B rationale

Polyuria, or excessive urination, is not a common adverse effect of magnesium sulfate therapy. It is more likely to be caused by other factors.

Choice C rationale

Hyporeflexia, or diminished reflexes, is a significant adverse effect of magnesium sulfate therapy. It indicates magnesium toxicity and requires immediate attention.

Choice D rationale

Tachypnea, or rapid breathing, is not a common adverse effect of magnesium sulfate therapy. It is more likely to be caused by other factors.

Choice A rationale

Serum bilirubin is not the priority test for hyperemesis gravidarum. It is more relevant for assessing liver function and jaundice.

Choice B rationale

Liver enzymes may be elevated in hyperemesis gravidarum, but they are not the priority test. The primary concern is dehydration and electrolyte imbalance.

Choice C rationale

A CBC can provide information on the client’s overall health, but it is not the priority test for hyperemesis gravidarum. The focus should be on assessing hydration status.

Choice D rationale

Urinalysis for ketones is the priority test because it helps assess the severity of dehydration and malnutrition. The presence of ketones indicates that the body is breaking down fat for energy, which is a sign of inadequate caloric intake.