A client at 20 weeks gestation reports discomfort after amniocentesis procedure to the nurse. Which of the following assessment findings warrants priority action by the nurse?

Explanation:

A. "Daily jogging for up to 30 minutes is fine throughout the pregnancy."

This response suggests that moderate-intensity exercise like jogging is safe throughout pregnancy. However, it's important to note that individual exercise recommendations can vary based on the woman's health status, pre-pregnancy fitness level, any pregnancy complications, and guidance from her healthcare provider. While moderate exercise is generally encouraged during pregnancy, it's crucial for the client to consult her healthcare provider for personalized recommendations.

B. "Activities that raise the body temperature, such as saunas and hot tubs, are safe until the third trimester."

This response addresses the importance of avoiding activities that can lead to overheating, such as using saunas or hot tubs, especially during the first trimester when fetal development is particularly sensitive. However, it doesn't specifically address general exercise guidelines.

C. "It is recommended that pregnant clients limit their exercise routine to stretching activities on a mat several times a week."

This response suggests a very conservative approach to exercise during pregnancy, focusing primarily on stretching activities. While stretching can be beneficial, it's important for pregnant individuals to engage in a variety of exercises, including aerobic and strength-training activities, as long as they are safe and appropriate for their pregnancy status.

D. "Exercising during pregnancy is not recommended."

This response is not accurate. Exercise during pregnancy is generally recommended and has numerous benefits for both the mother and baby, including improved cardiovascular health, reduced risk of gestational diabetes, enhanced mood, and better overall well-being. However, the type, intensity, and duration of exercise should be tailored to the individual's needs and guided by healthcare providers.

Explanation:

A. Evaluate neurologic status every 8 hr.

While monitoring neurologic status is important in clients with severe gestational hypertension to assess for signs of impending eclampsia (seizures), more frequent monitoring is typically required, such as every 4 hours or even more frequently depending on the severity of the condition. Therefore, evaluating neurologic status every 8 hours is not sufficient for this client.

B. Provide a dark, quiet environment.

Creating a calm and low-stimulation environment helps to reduce the risk of seizures, which can be triggered by bright lights and loud noises in clients with severe gestational hypertension.

C. Administer magnesium sulfate IV.

Magnesium sulfate is commonly used to prevent seizures in clients with severe gestational hypertension (preeclampsia). It is a standard treatment to prevent eclampsia, a serious complication of preeclampsia characterized by seizures. Therefore, the nurse should expect to administer magnesium sulfate IV as part of the management plan for severe gestational hypertension.

D. Ensure that calcium gluconate is readily available.

Magnesium sulfate, while effective in preventing seizures, can lead to magnesium toxicity if levels become too high. Calcium gluconate is the antidote for magnesium sulfate toxicity. Therefore, the nurse should ensure that calcium gluconate is readily available to counteract any potential magnesium toxicity that may occur during magnesium sulfate administration.

E. Assess respiratory status every 4 hr.

Monitor and record vital signs (blood pressure, pulse, respirations, O2 saturation) every 1 hour x’s 8 hours after maintenance infusion is started and vital signs for bolus infusion are complete.If respiratory rate < 12 breaths/min, draw magnesium level, notify HCP, and observe closely.