The nurse is caring for a postpartum client who delivered 5 hours ago, and has saturated a perineal pad with clots within the last 15 minutes.Which action is most important for the nurse to implement?

 

Condition: Preeclampsia with severe features.

2 actions:

Administer magnesium sulfate as prescribed,

Monitor for signs of magnesium toxicity.

2 parameters:

Urine output of at least 30 mL/hour,

Deep tendon reflexes.

Rationale for correct condition: Preeclampsia with severe features is indicated by the elevated blood pressure of 170/98 mm Hg and the need for magnesium sulfate. The goal is to prevent eclampsia and manage severe preeclampsia symptoms. The variable decelerations noted in the fetal heart rate are consistent with preeclampsia. The client's blood pressure is critically high, requiring immediate intervention. Magnesium sulfate is used to prevent seizures in severe preeclampsia.

Rationale for actions: Administering magnesium sulfate is essential to prevent seizures associated with severe preeclampsia. It stabilizes the client and reduces the risk of eclampsia. Monitoring for signs of magnesium toxicity ensures safe administration. Symptoms like respiratory depression and loss of reflexes indicate toxicity, requiring dose adjustment. Preparing for an emergency cesarean section is not immediately necessary. Placing the client in a supine position can worsen blood pressure. Restricting fluid intake is not a priority without signs of fluid overload.

Rationale for parameters: Monitoring urine output ensures kidney function and fluid balance. Preeclampsia can affect renal function, making this parameter critical. Deep tendon reflexes help assess neurological status and detect magnesium toxicity early. Changes in reflexes guide dosage adjustments. Fetal heart rate variability is important but secondary here. Oxygen saturation is stable and less relevant. Serum magnesium levels above 8 mg/dL indicate toxicity and are not the target.

Rationale for incorrect conditions: Gestational hypertension involves elevated blood pressure without severe features or the need for magnesium sulfate. Placental abruption would present with more severe pain and bleeding. Preterm labor does not align with the focus on hypertension and magnesium sulfate use.

Assessing vital signs is important but not the most immediate action for heavy postpartum bleeding. It provides information about the client's current status but does not address the bleeding directly.

Choice B rationale

Increasing the IV infusion rate can help manage blood loss by maintaining blood volume, but it is not the first action to take when managing postpartum hemorrhage.

Choice C rationale

Notifying the healthcare provider is important but secondary to addressing the immediate cause of the bleeding. The provider will need information about the client's status and the actions taken to manage the situation.

Choice D rationale

Massaging the fundus is the most immediate and effective action to reduce postpartum hemorrhage. It stimulates uterine contractions, which helps to clamp down on the blood vessels and stop the bleeding.