Complete the following sentence by using the list of options.

The nurse should wear an

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.

A. Positive clonus: Clonus indicates neuromuscular irritability and is a sign of worsening preeclampsia rather than therapeutic control. The presence of clonus suggests inadequate suppression of central nervous system excitability.

B. Respiratory rate 10/min: A respiratory rate of 10 per minute indicates respiratory depression, which is a sign of magnesium toxicity. This finding reflects an adverse effect rather than a therapeutic response.

C. Deep tendon reflexes 2+: Normal deep tendon reflexes indicate that magnesium levels are within the therapeutic range. This finding reflects effective seizure prophylaxis without evidence of magnesium toxicity.

D. Urinary output 20 mL/hr: Low urine output suggests impaired renal clearance of magnesium, increasing the risk for toxicity. Adequate urine output is needed to safely eliminate magnesium, so this finding is concerning rather than therapeutic.

Rationale for correct choices:

• Compartment syndrome: The client demonstrates classic neurovascular compromise: severe escalating pain, numbness, inability to move toes, cool extremity, absent distal pulses, delayed capillary refill, and increasing edema. These findings reflect increased intracompartmental pressure compromising circulation and nerve function. This is a limb-threatening postoperative emergency following fractures and splinting.

• Osteomyelitis: The client has an open fracture with internal fixation, drainage at the surgical site, fever, and a marked rise in WBC count. Open fractures significantly increase the risk of bone infection due to direct contamination. Persistent fever and leukocytosis support developing osteomyelitis rather than normal postoperative inflammation.

Rationale for incorrect choices:

• Fat embolism syndrome: Fat embolism typically presents with acute respiratory distress, hypoxemia, altered mental status, and petechial rash. This client maintains adequate oxygen saturation and denies shortness of breath, making this condition less likely at this time.

• Deep vein thrombosis: DVT commonly presents with unilateral calf pain, warmth, erythema, and swelling, but does not cause absent pulses, motor loss, or sensory deficits. The acute neurovascular changes seen here point to arterial compromise rather than venous obstruction.