A nurse is caring for a female client who is at 12 weeks of gestation in the prenatal clinic.

Exhibits

A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

Choice A rationale: Calcium gluconate must be readily available whenever magnesium sulfate is administered because it serves as the antidote for magnesium toxicity. Magnesium sulfate depresses neuromuscular transmission and the central nervous system, which can lead to respiratory depression, hypotension, and cardiac arrest if serum levels become excessive. Having calcium gluconate on hand allows for immediate reversal of these life-threatening effects. This is a critical safety measure and therefore a required nursing action.

Choice B rationale: Respiratory status must be assessed at least every hour during magnesium sulfate therapy because respiratory depression is a primary sign of magnesium toxicity. Normal adult respiratory rate is 12 to 20 breaths per minute, and a rate below 12/min is concerning. Magnesium depresses the respiratory center in the medulla, and early recognition of hypoventilation is essential to prevent hypoxia and arrest. Thus, frequent respiratory monitoring is a priority nursing action.

Choice C rationale: Monitoring intake and output is essential because magnesium sulfate is excreted almost entirely by the kidneys. Oliguria, defined as urine output less than 30 mL/hr, increases the risk of magnesium accumulation and toxicity. Careful fluid balance assessment ensures adequate renal clearance and helps prevent complications such as pulmonary edema. Therefore, strict I&O monitoring is a critical nursing responsibility during magnesium sulfate therapy to ensure safe drug metabolism and excretion.

Choice D rationale: Intermittent fetal monitoring is not appropriate in this context. Magnesium sulfate administration and preterm labor with rupture of membranes require continuous fetal monitoring to detect early signs of distress. Intermittent monitoring risks missing decelerations or prolonged bradycardia. Continuous monitoring provides real-time assessment of fetal well-being and is the standard of care in high-risk obstetric situations. Therefore, intermittent monitoring is not a correct action and should not be selected.

Choice E rationale: Supine positioning is contraindicated in pregnancy, especially in the third trimester, because the gravid uterus compresses the inferior vena cava, leading to supine hypotensive syndrome. This decreases venous return, cardiac output, and uteroplacental perfusion, compromising both maternal and fetal oxygenation. The correct position is left lateral recumbent to optimize circulation. Therefore, placing the client supine is unsafe and not an appropriate nursing action in this scenario.

Choice A rationale

Hydrotherapy, like immersion in a tub or shower, is a nonpharmacological comfort measure for labor pain management. The therapeutic temperature of the water should indeed be maintained between 36 to 37°C (about 96.8 to 98.6°F). This range ensures the water is comfortably warm, promoting muscle relaxation, reducing pain perception, and avoiding potential maternal hyperthermia or fetal distress due to extreme temperatures.

Choice B rationale

Counterpressure is a technique used to relieve back pain caused by pressure of the fetal occiput against the sacrum, commonly known as "back labor.”. It involves steady, strong pressure applied by a support person to the sacral area or lower back, not the upper abdomen. Applying pressure to the upper abdomen would be ineffective and potentially uncomfortable for the client.

Choice C rationale

Effleurage is a light, rhythmic, stroking massage, often applied to the abdomen, used primarily during contractions in the first stage of labor to promote relaxation and distract from pain. It is generally not used during the pushing phase (second stage), as the client's focus shifts to bearing down and expelling the fetus, making effleurage distracting and ineffective.

Choice D rationale

Transcutaneous Electrical Nerve Stimulation (TENS) involves applying mild electrical currents via electrodes to the skin. During labor, the electrodes are typically placed on the lower back (sacral area) to block pain signals related to contractions as they travel up the spinal cord. Applying the TENS unit to the lower abdomen is not the standard placement for optimal labor pain relief.