A nurse is teaching a client who is postpartum and has an order for an injection of Rh, (D) immunoglobulin. Which of the following should be included in the teaching?

A. Keep calcium gluconate readily available: Magnesium sulfate can cause toxicity, including respiratory depression and cardiac arrest. Calcium gluconate is the antidote and must be available at the bedside in case of adverse effects. This is a critical safety measure during therapy.

B. Check urinary output every 2 hr: Magnesium is excreted through the kidneys, so reduced urine output can lead to accumulation and toxicity. Monitoring urinary output ensures the client is clearing the medication effectively. Output should remain ≥30 mL/hr.

C. Check deep tendon reflexes every 1 hr: Loss of deep tendon reflexes is an early sign of magnesium toxicity. Hourly assessments help detect neuromuscular depression and guide dosage adjustments. Reflex monitoring is essential during magnesium infusion.

D. Provide intermittent fetal monitoring: This is inappropriate in the context of severe hypertension and magnesium sulfate administration. Continuous fetal monitoring is required to assess fetal well-being and detect signs of distress, especially in a high-risk situation.

E. Report respiratory rate of less than 12 breaths/min to the provider: Respiratory depression is a major sign of magnesium toxicity. A respiratory rate below 12 indicates central nervous system depression and requires immediate attention. Prompt reporting allows timely intervention to prevent complications.

A. Blood pressure of 140/90 mmHg: While elevated, this blood pressure reading is at the threshold of hypertension and is common in HELLP syndrome. It is not the most alarming finding unless it continues to rise or is accompanied by signs of end-organ damage.

B. Platelets 250,000/mm³: This is within the normal range and does not reflect thrombocytopenia, which is a hallmark of HELLP syndrome. A concerning platelet count would be below 100,000/mm³, suggesting a risk for bleeding complications.

C. Right upper quadrant pain: This symptom may indicate liver involvement, such as hepatic swelling or rupture, and is a serious sign in HELLP syndrome. It can signal worsening disease and the need for immediate evaluation and possible intervention.

D. Fetus expected weight for gestation: A fetus growing appropriately is a reassuring sign in pregnancy. HELLP syndrome can lead to fetal growth restriction, but expected weight indicates adequate placental function at the moment and is not an urgent concern.