The nurse is observing a parent holding a preterm infant. The infant is sneezing, yawning, and extending the arms and legs. What action by the nurse is best?

Choice A) Prepare for an emergency cesarean birth is incorrect because this is not a priority or appropriate action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV.

Preeclampsia is a condition that causes high blood pressure, proteinuria, and edema during pregnancy. It can lead to complications such as eclampsia, which is seizures, or HELLP syndrome, which is hemolysis, elevated liver enzymes, and low platelets. Magnesium sulfate is a medication that helps to prevent or treat seizures in preeclamptic clients by relaxing the muscles and nerves. However, it can also cause side effects such as respiratory depression, hypotension, or loss of reflexes. Preparing for an emergency cesarean birth may be necessary if the client has severe preeclampsia or fetal distress, but it does not address the immediate problem of magnesium toxicity. Therefore, this action should be done only when indicated by the physician and after stabilizing the client's condition.

Choice B) Discontinue the medication infusion is correct because this is a priority and appropriate action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. Discontinuing the medication infusion can help to stop or reduce the adverse effects of magnesium sulfate, such as respiratory depression, hypotension, or loss of reflexes. These effects can indicate magnesium toxicity, which is a life-threatening condition that can cause cardiac arrest or coma. The nurse should also notify the physician and prepare to administer calcium gluconate, which is an antidote for magnesium toxicity. Therefore, this action should be done as soon as possible for clients who show signs of magnesium overdose.

Choice C) Place the client in Trendelenburg's position is incorrect because this is not a safe or suitable action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV.

Trendelenburg's position means lying on the back with the head lower than the feet. It is sometimes used to improve blood flow to the brain or heart in cases of shock or hypotension. However, it can also cause complications such as increased intracranial pressure, decreased lung expansion, aspiration, or acid reflux. Moreover, it does not help to reverse or prevent the side effects of magnesium sulfate, such as respiratory depression, hypotension, or loss of reflexes. Therefore, this action should be avoided or used with caution for clients who are receiving magnesium sulfate IV.

Choice D) Assess maternal blood glucose is incorrect because this is not a relevant or necessary action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. Blood glucose is the level of sugar in the blood that provides energy to the cells. It is measured by a blood test or a finger stick test. It can be affected by various factors such as diet, exercise, medication, or pregnancy. Assessing maternal blood glucose may be important for clients who have diabetes or gestational diabetes, which are conditions that cause high blood sugar levels that can harm the mother and the baby. However, it does not relate to preeclampsia or magnesium sulfate, which are conditions that affect blood pressure and nerve function. Therefore, this action should be done only when indicated by the physician and according to the client's history and needs.

Choice A) Report of absent breast pain is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client does not have mastitis or engorgement. Mastitis is an infection of the breast tissue that causes pain, swelling, redness, and fever. Engorgement is a condition where the breasts become overfilled with milk, causing pain, hardness, and leakage. Both conditions are common in postpartum women who are breastfeeding, but they are not related to methylergonovine or uterine bleeding. Therefore, this response is irrelevant and inaccurate.

Choice B) Increase in lochia is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the medication was ineffective or that the client has a complication. Lochia is the vaginal discharge that consists of blood, mucus, and tissue from the uterus after childbirth. It usually lasts for about 4 to 6 weeks and gradually decreases in amount and color. Methylergonovine is a medication that helps to control uterine bleeding by improving the tone and contractions of the uterus. An increase in lochia may mean that methylergonovine did not work well or that the client has a problem such as retained placenta, infection, or subinvolution. Therefore, this response is opposite and inaccurate.

Choice C) Increase in blood pressure is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client has a side effect or a risk factor. Blood pressure is the force of blood against the walls of the arteries. It is measured by two numbers: systolic (the pressure when the heart beats) and diastolic (the pressure when the heart rests). The normal range for blood pressure is 120/80 mm Hg or lower. Methylergonovine is a medication that can cause vasoconstriction, which means narrowing of the blood vessels and increasing of the blood pressure. This can lead to complications such as hypertension, stroke, or heart attack. Therefore, this response is adverse and inaccurate.

Choice D) Fundus firm to palpation is correct because this is a finding that indicates that the medication was effective and that the client has a good outcome. The fundus is the upper part of the uterus that can be felt through the abdomen after childbirth. It should be firm, midline, and at or below the level of the navel. A firm fundus means that the uterus has contracted well and stopped bleeding. Methylergonovine is a medication that helps to achieve this by improving the tone and contractions of the uterus. Therefore, this response is positive and accurate.