A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol, a synthetic prostaglandin E drug.
How should the nurse respond?

Condition: Preeclampsia with severe features.

2 actions:

Administer magnesium sulfate as prescribed,

Monitor for signs of magnesium toxicity.

2 parameters:

Urine output of at least 30 mL/hour,

Deep tendon reflexes.

Rationale for correct condition: Preeclampsia with severe features is indicated by the elevated blood pressure of 170/98 mm Hg and the need for magnesium sulfate. The goal is to prevent eclampsia and manage severe preeclampsia symptoms. The variable decelerations noted in the fetal heart rate are consistent with preeclampsia. The client's blood pressure is critically high, requiring immediate intervention. Magnesium sulfate is used to prevent seizures in severe preeclampsia.

Rationale for actions: Administering magnesium sulfate is essential to prevent seizures associated with severe preeclampsia. It stabilizes the client and reduces the risk of eclampsia. Monitoring for signs of magnesium toxicity ensures safe administration. Symptoms like respiratory depression and loss of reflexes indicate toxicity, requiring dose adjustment. Preparing for an emergency cesarean section is not immediately necessary. Placing the client in a supine position can worsen blood pressure. Restricting fluid intake is not a priority without signs of fluid overload.

Rationale for parameters: Monitoring urine output ensures kidney function and fluid balance. Preeclampsia can affect renal function, making this parameter critical. Deep tendon reflexes help assess neurological status and detect magnesium toxicity early. Changes in reflexes guide dosage adjustments. Fetal heart rate variability is important but secondary here. Oxygen saturation is stable and less relevant. Serum magnesium levels above 8 mg/dL indicate toxicity and are not the target.

Rationale for incorrect conditions: Gestational hypertension involves elevated blood pressure without severe features or the need for magnesium sulfate. Placental abruption would present with more severe pain and bleeding. Preterm labor does not align with the focus on hypertension and magnesium sulfate use.

1. Blood pressure: 170/98 mm Hg: Abnormal. A blood pressure reading of 170/98 mm Hg is high, especially in the context of pregnancy, where it may indicate gestational hypertension or the potential for preeclampsia. This needs to be monitored closely.
2. Pain rating: 5/10 with contractions: Normal. A pain rating of 5/10 is typical during labor, especially at this stage of dilation (4 cm). Pain management can be adjusted based on the client's preference and progress.
3. Variable decelerations: 20 seconds: Normal. Occasional variable decelerations (drops in fetal heart rate that last for less than 30 seconds) can occur during labor, often due to umbilical cord compression. As long as the decelerations are brief and not repetitive or severe, they are typically not concerning.
4. Magnesium sulfate infusion ongoing: Normal. The magnesium sulfate infusion is prescribed to manage potential complications, likely to prevent preterm labor or to prevent seizures in the event of preeclampsia. Its ongoing use is appropriate for this client at this stage.