The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has risen from 110/60 mmHg to 140/90 mmHg.
Which nursing protocol is of the highest priority?

Answer: D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

Rationale:

• Choice A: Clean up the spit-up and assist the mother with the diaper change is not the first priority. While cleaning is important, ensuring the baby's airway is clear and preventing aspiration (inhaling vomit into the lungs) is more critical.
• Choice B: Position the newborn on the side and suction the mouth and nares with a bulb syringe is only necessary if the baby shows signs of respiratory distress, such as coughing, wheezing, or difficulty breathing. Unless aspiration is suspected, suctioning can irritate the nasal passages and worsen the situation.
• Choice C: Position the newborn with the head lower than the feet can actually increase the risk of aspiration. Fluids can pool in the back of the throat and be more easily inhaled.
• Choice D: Sit the newborn upright and burp by gently rubbing or patting the upper back is the most appropriate first action. This position helps bring up any air swallowed during feeding, reducing the likelihood of spitting up. Gently rubbing or patting the back encourages the burp reflex.

Additional Notes:

• After burping the baby, the nurse can assess the amount of spit-up and clean the baby and surrounding area as needed.
• If the baby shows signs of respiratory distress after burping, suctioning may be necessary. However, this should only be done by a healthcare professional.
• If the spitting up is frequent or forceful, the nurse should consult with a doctor to rule out any underlying medical conditions.

Choice A rationale

A client who is 3 weeks postpartum and feeling tired all the time is a common scenario. Adjusting to a new baby can be challenging and it’s normal for new mothers to feel overwhelmed and fatigued. The nurse’s response should be empathetic and supportive,

encouraging the client to share more about her situation. This could help the nurse understand the client’s support system and provide appropriate advice or resources.

Choice B rationale

While it’s important to ensure that the client isn’t overexerting herself with chores, suggesting that she shouldn’t be doing any at all might not be practical or feasible. The presence and involvement of family members can vary greatly, and while their help can be beneficial, it’s not the only factor in managing postpartum fatigue.

Choice C rationale

It’s indeed common for new mothers to feel worn out for the first few months. However, simply advising the client to rest when the baby is sleeping might not address the root cause of her fatigue. It’s also important to consider other factors such as nutrition, emotional well- being, and available support.

Choice D rationale

Telling the client that it’s normal to feel fatigued for the first few weeks might minimize her feelings. Each person’s postpartum experience is unique, and it’s crucial to validate her feelings and provide individualized care.