A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia.
Which of the following responses by the nurse is appropriate?

Choice A rationale: The client’s temperature is 38.3°C (101°F), which is above the normal range (36.5-37.2°C or 97.7-99°F). This could indicate an infection, which is a common postpartum complication. Fever in the postpartum period can be due to endometritis, wound infection, mastitis, or urinary tract infection. Given the client’s report of a burning sensation during urination, a urinary tract infection could be a possibility. This finding requires immediate follow-up.

Choice B rationale: The client’s pulse rate is 110/min, which is above the normal range (60-100/min). This could indicate tachycardia, which can be a response to fever, pain, anxiety, or blood loss. Given the client’s elevated temperature and report of pain, this finding requires immediate follow-up.

Choice C rationale: The client’s respiratory rate is 22/min, which is within the normal range (12-20/min). While it’s slightly elevated, it’s not as concerning as the other findings. However, the nurse should continue to monitor the client’s respiratory rate along with other vital signs.

Choice D rationale: The client’s blood pressure is 140/90 mm Hg, which is higher than the normal range (90-120/60-80 mm Hg). This could indicate hypertension, which can be a complication in the postpartum period. Hypertension can lead to complications such as preeclampsia or eclampsia, which can be life-threatening. This finding requires immediate follow-up.

Choice E rationale: The client has a large amount of lochia rubra. Lochia rubra is normal for the first few days after delivery, but a large amount could indicate postpartum hemorrhage, especially if it’s accompanied by signs of hypovolemia such as tachycardia and hypotension. This finding requires immediate follow-up.

Choice F rationale: The client reports pain as 5 on a scale of 0 to 10. While pain is expected after a vaginal delivery, especially with an episiotomy, it should be manageable with analgesics. If the client’s pain is not well-controlled, it could indicate a complication such as infection or hematoma at the episiotomy site. However, given the information provided, this finding does not require immediate follow-up as much as the others.

Choice G rationale: The client has 3+ peripheral edema in bilateral lower extremities. While some edema is normal during pregnancy and the postpartum period, 3+ edema could indicate a complication such as deep vein thrombosis, especially if it’s accompanied by pain, warmth, or redness. This finding requires immediate follow-up.

Choice A rationale
Hypotension is a known adverse effect of epidural analgesia. The epidural can block sympathetic nerve fibers, which can lead to vasodilation and a drop in blood pressure.
Choice B rationale
A maternal temperature of 37.4 C (99.4 F) is within the normal range and is not typically a cause for concern. While epidural analgesia can potentially cause a slight increase in body temperature, a significant fever is not a common side effect.
Choice C rationale

Polyuria, or excessive urination, is not a typical side effect of epidural analgesia. While the epidural can affect nerve signals to the bladder, it does not typically cause the kidneys to produce more urine.
Choice D rationale
A fetal heart rate of 152/min is within the normal range for a fetus (110-160 beats per minute). While epidural analgesia can potentially affect the baby’s heart rate if it causes significant maternal hypotension, a heart rate of 152/min is not indicative of a problem. CytomegalovirusCytomegalovirus Explore