A postpartum patient has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia.
It has been about 8 hours since her vaginal delivery and upon assessment the nurse finds the following: temperature 98.3°F, pulse rate 88 beats/min, respiratory rate 16 breaths/min, blood pressure (BP) 148/78 mm Hg, 2+ deep tendon reflexes, 100 cc of clear yellow urine over the past hour, heavy rubra lochia, and a boggy fundus.
What is the most appropriate action for the nurse to take?
Administering a uterotonic medication to control bleeding.
Call for a stat magnesium sulfate level.
Administer additional magnesium sulfate to maintain therapeutic levels.
Monitoring the patient's blood pressure and reflexes.
The Correct Answer is A
Choice A rationale
A boggy (uncontracted) fundus coupled with heavy rubra lochia is the cardinal sign of postpartum uterine atony, the most common cause of postpartum hemorrhage. The nurse's priority is to stimulate uterine contraction to compress the intramyometrial blood vessels, thereby controlling bleeding. This requires immediate intervention, usually fundal massage and administering a uterotonic medication (e.g., oxytocin) to prevent life-threatening blood loss.
Choice B rationale
While the patient is receiving magnesium sulfate, which requires monitoring, her respiratory rate (16 breaths/min, normal 12-20) and deep tendon reflexes (2+, normal range 1+ to 3+) are within therapeutic and acceptable ranges. A boggy fundus and heavy bleeding represent an acute life threat from hemorrhage, which is a higher priority than checking a stat magnesium level unless signs of toxicity (e.g., RR < 12 or absent reflexes) were present.
Choice C rationale
The patient's current clinical picture, specifically the heavy bleeding, contraindicates increasing the dose of magnesium sulfate. Magnesium sulfate is a central nervous system depressant and a smooth muscle relaxant; it can inhibit uterine contractility and exacerbate the ongoing postpartum hemorrhage caused by the boggy fundus. Therefore, increasing the dose would be dangerous and inappropriate in this hemorrhagic situation.
Choice D rationale
Although monitoring BP (currently 148/78 mm Hg, normal BP in preeclampsia treatment) and reflexes is important for magnesium sulfate therapy, immediate action is required to address the signs of potential hemorrhage. The boggy fundus is an emergency finding that necessitates intervention to prevent maternal compromise and potentially irreversible hypovolemic shock. Monitoring alone would delay critical, time-sensitive treatment. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Preterm infants have a reduced ability to produce heat due to less brown fat stores, thin skin, and a large surface area-to-body weight ratio. Cold stress causes the infant to metabolize stored fat and glucose to generate heat (non-shivering thermogenesis). This process increases oxygen and glucose consumption, which is particularly dangerous for infants with respiratory distress syndrome, potentially worsening hypoxemia and acidosis. —.
Choice B rationale
While preventing discomfort is important, the primary rationale for preventing cold stress is based on the physiological complications it precipitates, which are life-threatening, such as metabolic acidosis, hypoglycemia, and respiratory deterioration. Discomfort is a subjective and less critical concern compared to the potentially fatal metabolic and respiratory consequences. —.
Choice C rationale
Parent-infant bonding is primarily encouraged through practices like skin-to-skin contact (kangaroo care) and holding. While a neutral thermal environment facilitates these activities, preventing cold stress is a critical survival intervention to maintain physiological homeostasis, which supersedes bonding as the primary rationale for temperature management. —.
Choice D rationale
Neonates, especially preterm infants, lack the shivering mechanism for thermogenesis. They rely on non-shivering thermogenesis (NST), which involves the metabolism of brown fat. This process consumes significant oxygen and glucose, leading to caloric expenditure and placing a high demand on the cardiorespiratory system, which is the core problem, not shivering itself. —. ##
Correct Answer is A
Explanation
Choice A rationale
Small for gestational age (SGA) is scientifically defined as a newborn whose birth weight is below the 10th percentile for their specific gestational age, indicating restricted fetal growth. These infants have lower glycogen stores, a critical energy source, and decreased gluconeogenesis capacity, leading to rapid depletion of glucose reserves postpartum. This deficiency significantly increases the newborn's risk for hypoglycemia (blood glucose <40 to 45 mg/dL), requiring frequent monitoring and early feeding interventions.
Choice B rationale
A weight below the 5th percentile is a more severe classification, sometimes called severe SGA or fetal growth restriction (FGR), but the general definition of SGA remains the 10th percentile cutoff. While SGA infants may have a higher hematocrit (polycythemia), which is a risk factor for hyperbilirubinemia due to increased red blood cell breakdown, hypoglycemia is the most immediate and common metabolic risk due to low energy stores.
Choice C rationale
A birth weight above the 90th percentile for gestational age defines a large for gestational age (LGA) or macrosomic infant, the complete opposite of SGA. These infants, often born to diabetic mothers, are at a higher risk for birth trauma, shoulder dystocia, and hypoglycemia, but are not defined as SGA. Polycythemia (central hematocrit >65%) is a risk for SGA infants, but SGA is not defined by weight above the 90th percentile.
Choice D rationale
The 50th percentile represents the average or median weight for that gestational age, classifying the infant as appropriate for gestational age (AGA), not SGA. Meconium aspiration syndrome is primarily a risk associated with post-term infants (born ≥42 weeks) or term/SGA infants experiencing fetal distress and asphyxia, which triggers meconium passage in utero, not a direct or defining metabolic risk of SGA.
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