The provider orders magnesium sulfate to treat a primigravida client's severe pre-eclampsia.

The medication is available as 60 grams of magnesium sulfate in 1000 mL of lactated ringer's at a rate of 4 grams/hr. What is the starting rate of the infusion? Record numerical answers only.

Round the answer to the nearest whole number.

Choice A rationale

Contractions that are only 20 mm Hg in strength with a baseline resting tone of 5 to 8 mm Hg indicate hypotonic uterine dysfunction. This is characterized by insufficient uterine contraction power, not hypertonic resting tone. Oxytocin is an exogenous hormone that mimics the effects of the naturally released hormone, acting on uterine smooth muscle cells to increase the frequency, duration, and strength (intensity) of the contractions, which should ideally be 50 to 80 mm Hg during active labor.

Choice B rationale

Suggesting relaxation is inappropriate because these contraction patterns are ineffective and unlikely to spontaneously strengthen enough to cause adequate cervical change. Hypotonic contractions typically lead to a protracted labor pattern. The smooth muscle fibers of the uterus require sufficient stimulation to fully activate the contractile proteins actin and myosin. The low intensity and inadequate pressure of these contractions will not result in optimal cervical effacement and dilation.

Choice C rationale

These contractions are hypotonic, not hypertonic. Hypertonic contractions are characterized by high resting tone (above 15 mm Hg) and often painful, ineffective, erratic contractions. A period of rest is generally recommended for hypertonic contractions to reduce uterine irritability and oxygen consumption. However, for hypotonic dysfunction, augmentation (Choice A) is usually required to safely expedite the labor process and reduce risk of infection.

Choice D rationale

While upright positions like sitting or walking can use gravity to help the fetal head apply pressure to the cervix and stimulate endogenous oxytocin release, this response is less effective than recognizing the need for potential pharmacological augmentation. The contractions are described as rarely higher than 20 mm Hg, suggesting a significant need for intervention beyond simple position change to achieve the necessary 50 to 80 mm Hg intensity for progression.

Choice A rationale

Fundal height measurement assesses fetal growth, which is important but less critical than fetal well-being in a bleeding emergency. Placenta previa involves placental implantation near or over the cervical os, causing painless bleeding. Fetal distress from hypovolemia or prematurity is the most immediate life threat. The normal fundal height range is approximately equal to the weeks of gestation ± 2 cm after 20 weeks.

Choice B rationale

A digital vaginal examination is contraindicated in a client with painless, bright red bleeding suspicious of placenta previa. This action could accidentally rupture the placenta or vessels, leading to catastrophic hemorrhage and fetal distress by potentially causing placental separation or tearing of the vasa previa if present.

Choice C rationale

Assessment of maternal temperature is part of a routine vital sign assessment, mainly to detect infection (chorioamnionitis), which can cause preterm labor or rupture of membranes, but is not the priority over assessing the immediate maternal and fetal response to the hemorrhage. Normal maternal temperature is about 36.1°C to 37.2°C (97.0°F to 99.0°F).

Choice D rationale

Continuous monitoring of the fetal heart rate (FHR) and contraction patterns is the most crucial assessment to determine fetal status and well-being. Bleeding from placenta previa can quickly compromise uteroplacental perfusion, leading to fetal hypoxia, distress (e.g., non-reassuring FHR patterns), or premature labor, necessitating immediate intervention. Normal FHR is 110-160 beats per minute.