What is the most crucial assessment for the nurse to perform after administering epidural anesthesia to a patient who is at 40 weeks gestation?

Choice B rationale

When preparing to administer magnesium sulfate to a laboring client with elevated blood pressure, ensuring that calcium gluconate is immediately available is of the highest priority. Calcium gluconate is the antidote for magnesium sulfate toxicity, and having it readily available is crucial in case of an overdose.

Choice A rationale

While assessing deep tendon reflexes (DTRs) every 4 hours is an important part of monitoring a client receiving magnesium sulfate, it is not the most immediate priority when preparing to administer the medication.

Choice C rationale

Inserting a Foley catheter with a urimeter to monitor hourly output is an important part of the overall management of a client receiving magnesium sulfate. However, it is not the most immediate priority when preparing to administer the medication.

Choice D rationale

Providing a quiet environment with subdued lighting can contribute to the comfort of a laboring client. However, it is not the most immediate priority when preparing to administer magnesium sulfate.

Choice A rationale

A client at 32 weeks gestation reporting nausea, vomiting, and elevated blood pressure could be showing signs of a condition called gestational hypertension or preeclampsia. This condition can affect the health of both the mother and the baby, depending on how severe the issue is. Inspecting the client’s face for edema is a relevant next step because swelling in the face, hands, or fingers is a common symptom of preeclampsia.

Choice B rationale

While headaches can be a symptom of preeclampsia, asking about a history of cluster headaches may not be the most immediate concern in this situation. Cluster headaches are a specific type of headache that is not directly related to pregnancy or preeclampsia.

Choice C rationale

Determining the frequency of headaches could be useful in assessing the client’s overall health, but it may not be the most immediate concern when the client is showing potential signs of preeclampsia.

Choice D rationale

Monitoring and timing the client’s contractions would be more relevant if the client was in labor or showing signs of preterm labor. In this case, the client’s symptoms are more indicative of a hypertensive disorder of pregnancy.