A nurse is assisting with the admission of a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding.

Incomplete abortion is the initial diagnosis.

Which of the following actions should the nurse contribute to the client’s plan of care?

Choice A rationale:
Quickening is the term used to describe the first noticeable fetal movements felt by the pregnant person. It is often described as a fluttering or bubbling sensation in the lower abdomen.
Quickening typically occurs between 16 and 22 weeks of gestation, with an average of 18 weeks. It is a normal and reassuring sign that the pregnancy is progressing well.
The sensation of quickening is caused by the fetus moving its arms and legs, as well as by its body turning and rotating within the amniotic fluid.
It is important to note that not all pregnant women experience quickening at the same time, and some women may not feel it at all.
However, in this case, the client is at 16 weeks of gestation, which is within the typical timeframe for quickening to occur. Moreover, the client's description of "light fluttering in her stomach" is consistent with the sensation of quickening.

Choice B rationale:
Lightening is the term used to describe the descent of the fetus into the pelvis in preparation for labor.
It typically occurs in the last few weeks of pregnancy, and is often accompanied by a feeling of increased pressure in the pelvis and bladder.
The client in this question is only at 16 weeks of gestation, so it is too early for lightening to have occurred.

Choice C rationale:
Braxton Hicks contractions are irregular, painless contractions of the uterus that can occur throughout pregnancy.
They are often described as a tightening or hardening of the uterus, and they may come and go over a period of several hours. Braxton Hicks contractions are not a sign of labor, but they can sometimes be mistaken for it.
The client in this question did not describe any contractions, so Braxton Hicks contractions are not a likely explanation for her symptoms.

Choice D rationale:
Chloasma is a skin condition that is characterized by brown patches on the face.
It is also known as the "mask of pregnancy" because it is more common in pregnant women. Chloasma is caused by hormonal changes during pregnancy, and it typically fades after delivery.
The client in this question did not describe any skin changes, so chloasma is not a likely explanation for her symptoms

Choice A rationale:

A heart rate of 60/min is a sign of bradycardia, which can be a side effect of magnesium sulfate toxicity. Magnesium sulfate slows down neuromuscular transmission, which can lead to a decrease in heart rate. If the heart rate drops too low, it can compromise blood flow to vital organs, including the brain and heart. Therefore, a heart rate of 60/min is not a safe finding that would indicate the nurse should continue the infusion.

Choice C rationale:

A urine output of 50 ml in 4 hours is indicative of oliguria, which is a decreased urine output. Oliguria can be a sign of magnesium sulfate toxicity, as magnesium is primarily excreted through the kidneys. If the kidneys are not functioning properly, magnesium can build up in the body and lead to toxic levels. Therefore, a urine output of 50 ml in 4 hours is not a safe finding that would indicate the nurse should continue the infusion.

Choice D rationale:

Diminished deep-tendon reflexes are another sign of magnesium sulfate toxicity. Magnesium sulfate suppresses the nervous system, which can lead to decreased reflexes. If the reflexes are too diminished, it can indicate that the magnesium level in the body is too high. Therefore, diminished deep-tendon reflexes are not a safe finding that would indicate the nurse should continue the infusion.

Choice B rationale:

A respiratory rate of 16/min is within the normal range for an adult. It does not indicate any respiratory depression, which can be a side effect of magnesium sulfate toxicity. Therefore, a respiratory rate of 16/min is a safe finding that would indicate the nurse can continue the infusion.