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?

• Color: Consistent with genetic background

  • Interpretation: B) Sign of potential improvement
  • Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.

• Axillary Temperature: 36.3°C (97.4°F)

  • Interpretation: B) Sign of potential improvement
  • Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.

• Reflex Irritability: Cry

  • Interpretation: B) Sign of potential improvement
  • Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.

• Muscle Tone: Flaccid

  • Interpretation: C) Sign of potential worsening condition
  • Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.

• Respiration Effort: Good cry

  • Interpretation: B) Sign of potential improvement
  • Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.

• Heart Rate: 140/min

  • Interpretation: B) Sign of potential improvement
  • Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.

Choice A rationale:
Hypertension is not a typical symptom of abruptio placentae.
Choice B rationale:
Uterine tenderness is a common symptom of abruptio placentae.
Choice C rationale:
Fetal tachycardia is not a typical symptom of abruptio placentae.
Choice D rationale:
Leukorrhea is not associated with abruptio placentae.

The most likely finding the nurse should expect in a client experiencing abruptio placenta during labor is:

b. Uterine tenderness.

Here's why:

• Hypertension (a):While preeclampsia can increase the risk of abruptio placenta,it's not always present,and hypertension wouldn't be the immediate expected finding during the abruption event itself.
• Fetal tachycardia (c):This can occur in early stages of abruption to compensate for decreased oxygen supply,but as the abruption becomes more severe,fetal bradycardia is more likely due to oxygen deprivation.
• Leukorrhea (d):This is a white vaginal discharge and has no connection to abruptio placenta.

Uterine tenderness is a characteristic sign of abruptio placenta due to bleeding behind the placenta and irritation of the uterine muscle. This is often accompanied by:

• Vaginal bleeding (bright red or dark)
• Abdominal pain or cramping
• Sudden, ongoing uterine tightening or irritability
• Fetal distress (decreased fetal heart rate movements)

Therefore, option b is the most expected finding in this scenario.

Remember: Early recognition and prompt management of abruptio placenta are crucial for optimal outcomes for both mother and baby. If you suspect abruptio placenta, immediate medical attention is essential.