The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.
Which potential issue(s) place the client at risk? Select all that apply.

Choice A rationale

Flexion of all four extremities is a normal finding in newborns but does not specifically indicate successful transition to extrauterine life. It suggests good muscle tone, which is important, but vigorous crying is a more direct sign of effective respiratory effort and lung function.

Choice B rationale

A positive Babinski reflex is a normal reflexive response in newborns, indicating proper neurological function. However, it does not provide direct information about the newborn's respiratory or cardiovascular adaptation to life outside the womb.

Choice C rationale

Crying vigorously when stimulated is a strong indicator that the newborn is transitioning well to extrauterine life. It demonstrates that the infant's lungs are functioning properly, and they are capable of clearing airway secretions and maintaining adequate oxygenation, which are critical for survival outside the uterus.

Choice D rationale

A heart rate of 220 beats/minute is significantly higher than the normal range for newborns (120-160 beats/minute). Such tachycardia could indicate stress, dehydration, or underlying cardiac issues and does not reflect a normal transition to extrauterine life. .

Choice A rationale

Increasing IV fluids is a critical intervention to maintain maternal hemodynamic stability and prevent complications related to fluid imbalance. It helps support blood pressure and overall fluid status during labor and delivery.

Choice B rationale

While obtaining blood pressure is important for monitoring maternal status, it is not an immediate intervention compared to others listed. Blood pressure monitoring is part of routine assessment but not an emergency action.

Choice C rationale

Stopping the infusion of magnesium is essential if there are signs of magnesium toxicity or adverse effects. Magnesium can impact respiratory and cardiac function, so stopping the infusion is a priority.

Choice D rationale

Administering oxygen is an immediate intervention to ensure adequate oxygenation for both the mother and the fetus. It is crucial during labor and delivery to prevent hypoxia and related complications.

Choice E rationale

Obtaining serum magnesium level is necessary to assess for magnesium toxicity and guide further interventions. It provides important information on the mother's magnesium status and helps in making clinical decisions.

Choice F rationale

Preparing for a cesarean delivery is not an immediate intervention unless there are specific indications for surgical delivery. It should be based on clinical findings and maternal-fetal status.

Choice G rationale

Administering calcium gluconate is the antidote for magnesium toxicity and is an immediate intervention if signs of toxicity are present. It helps counteract the effects of excessive magnesium.

Choice H rationale

Preparing to prevent respiratory or cardiac arrest is a critical intervention in severe cases of magnesium toxicity, but it should be part of a broader emergency management plan rather than an immediate action. .