A nurse is assessing a newborn who was born at 42 weeks of gestation.
Which of the following findings should the nurse expect?

Based on the provided information:

• The client had a vacuum-assisted vaginal delivery with a heavy lochia and small clots noted.
• A boggy fundus and the need for oxytocin infusion also indicate an increased risk for excessive bleeding.

Given these observations, the client is at the highest risk for developing Postpartum hemorrhage (Option A) due to Heavy lochia with small clots (Option C).

So, the completed sentence would be:

"The client is at highest risk for developing Postpartum hemorrhage due to Heavy lochia with small clots."

Choice A rationale

A rapid pulse is not typically associated with magnesium toxicity. Magnesium toxicity more commonly affects the nervous and muscular systems.

Choice B rationale

Tingling in toes can be a sign of early magnesium sulfate effects but not necessarily toxicity. It may indicate that the medication is starting to affect the nervous system.

Choice C rationale

Cool skin temperature is not a common sign of magnesium toxicity. Symptoms of magnesium toxicity are more related to neuromuscular and respiratory function.

Choice D rationale

Absent deep tendon reflexes are a key indicator of magnesium toxicity. This finding suggests that magnesium levels are high enough to depress neuromuscular function, requiring immediate medical intervention. .