Exhibits

A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take?

Choice A rationale:

This manifestation, urine output of 20 mL/hr, is an adverse reaction to magnesium sulfate administration. Magnesium sulfate can lead to decreased urine output, and it is essential for the nurse to monitor the client's urinary output closely. Low urine output may indicate decreased kidney function, which can be a sign of magnesium toxicity.

Choice B rationale:

Hypertension is expected in a client with preeclampsia, and magnesium sulfate is used to help manage and prevent seizures in these cases. While it is essential to monitor and manage hypertension during pregnancy, it is not considered an adverse reaction to magnesium sulfate.

Choice C rationale:

Hyperglycemia is not a common adverse reaction to magnesium sulfate. Magnesium sulfate may cause central nervous system depression, muscle weakness, and respiratory depression, but it does not typically cause hyperglycemia.

Choice D rationale:

A respiratory rate of 16/min is within the normal range for an adult and is not indicative of an adverse reaction to magnesium sulfate. Magnesium sulfate can cause respiratory depression at higher doses, but a respiratory rate of 16/min does not raise immediate concerns.

Choice A rationale:

Newborn weight of 2.948 kg (6 lb 8 oz) does not place the client at risk for postpartum hemorrhage. Newborn weight is not directly related to the risk of postpartum hemorrhage in the mother.

Choice B rationale:

History of uterine atony places the client at risk for postpartum hemorrhage. Uterine atony is the most common cause of postpartum hemorrhage and refers to the inability of the uterus to contract effectively after childbirth, leading to excessive bleeding.

Choice C rationale:

Labor induction with oxytocin places the client at risk for postpartum hemorrhage. Oxytocin is commonly used to induce labor or augment contractions, but it can cause uterine hyperstimulation, leading to increased risk of postpartum hemorrhage.

Choice D rationale:

History of human papillomavirus (HPV) does not place the client at risk for postpartum hemorrhage. HPV is a sexually transmitted infection and does not have a direct connection to the risk of postpartum hemorrhage.

Choice E rationale:

Vacuum-assisted delivery places the client at risk for postpartum hemorrhage. Vacuum assisted delivery involves using a vacuum device to assist in the baby's delivery, and it can cause trauma to the birth canal, leading to increased bleeding risk in the mother.