A nurse on the labor and delivery unit is planning care for a client who has human immunodeficiency virus (HIV). Which of the following is an appropriate action for the nurse to take following the birth of the newborn?

This is because urine protein of 3+ is a sign of preeclampsia, which is a complication of pregnancy that involves high blood pressure and damage to the kidneys or other organs¹². Preeclampsia can cause serious problems for both the mother and the baby, such as fetal growth restriction, placental abruption, preterm birth, eclampsia, and HELLP syndrome¹². The nurse should report this finding to the provider and monitor the client's blood pressure, reflexes, and fetal well-being. The client may need medication to lower blood pressure and prevent seizures, such as magnesium sulfate or antihypertensives¹².

The other options are not correct because:
a) Deep tendon reflexes of 2+ are normal and do not indicate preeclampsia. Deep tendon reflexes are graded from 0 to 4+, with 2+ being the average response⁶. Increased reflexes (3+ or 4+) may suggest hyperreflexia, which can be a sign of preeclampsia or magnesium toxicity¹⁶.
b) Blood glucose of 110 mg/dL is normal and does not indicate preeclampsia. Blood glucose is the amount of sugar in the blood, and it can vary depending on the time of day, diet, and activity level. The normal range for blood glucose is 70 to 130 mg/dL before meals and less than 180 mg/dL after meals⁷. High blood glucose (hyperglycemia) can be a sign of gestational diabetes, which is a type of diabetes that develops during pregnancy⁷.
d) Hemoglobin of 13 g/dL is normal and does not indicate preeclampsia. Hemoglobin is the protein in red blood cells that carries oxygen throughout the body. The normal range for hemoglobin is 12 to 16 g/dL for women and 14 to 18 g/dL for men⁷. Low hemoglobin (anemia) can be a sign of iron deficiency, bleeding, or infection⁷.

A client who is in labor and reports an urge to have a bowel movement during contractions may be experiencing the transition phase of labor, which is the last and most intense part of the first stage of labor¹². The transition phase occurs when the cervix dilates from 8 to 10 cm and the baby descends into the birth canal¹². The pressure of the baby's head on the rectum can cause a sensation of needing to defecate¹². The transition phase can last from 15 minutes to an hour or more, and it can be accompanied by other signs, such as strong, regular, and painful contractions lasting 60 to 90 seconds; increased bloody show; nausea and vomiting; shaking and shivering; and emotional changes such as irritability, anxiety, or excitement¹²³.
The nurse should reassess the client who reports an urge to have a bowel movement during contractions because this may indicate that the client is close to delivering the baby and needs to be prepared for the second stage of labor, which involves pushing and giving birth¹². The nurse should check the client's cervical dilation, fetal heart rate, and maternal vital signs, and notify the provider if the client is fully dilated or shows signs of fetal or maternal distress¹². The nurse should also support the client's coping strategies, such as breathing techniques, relaxation methods, or pain relief options, and encourage the client not to push until instructed by the provider¹².

b) A sense of excitement and warm, flushed skin are not signs that require reassessment by the nurse. These are normal emotional and physiological responses to labor that reflect increased adrenaline levels and blood flow¹⁴. They do not indicate any complications or imminent delivery.
c) Progressive sacral discomfort during contractions is not a sign that requires reassessment by the nurse. This is a common symptom of labor that results from the pressure of the baby's head on the sacrum and nerves in the lower back¹⁴. It does not indicate any problems or imminent delivery.
d) Intense contractions lasting 45 to 60 seconds are not signs that require reassessment by the nurse. These are typical characteristics of active labor contractions, which occur when the cervix dilates from 4 to 8 cm¹⁴. They do not indicate any complications or imminent delivery.