A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

Correct Answer: A

Rationale: The correct answer is A: Respiratory depression. Respiratory depression is a serious sign of magnesium sulfate toxicity as it can progress to respiratory arrest. Magnesium sulfate acts as a central nervous system depressant, leading to muscle weakness and respiratory depression. Facial flushing is a common side effect but not indicative of toxicity. Nausea and drowsiness are common side effects of magnesium sulfate therapy and are not specific signs of toxicity. Reporting respiratory depression promptly is crucial to prevent further complications.

Correct Answer: A

Rationale: The correct answer is A because adequate oxygenation is a critical health outcome necessary for cellular function and overall well-being. Without sufficient oxygenation, other bodily functions can be compromised. Stable body temperature (B) is important but not as immediately life-threatening as inadequate oxygenation. Weight gain (C) is not a priority health outcome in this scenario. Heart rate recovery (D) is important but ensuring adequate oxygenation takes precedence in this case.

Correct Answer: B

Rationale: The correct answer is B because monitoring blood glucose levels is crucial in managing gestational diabetes to prevent complications for both the mother and baby. By regularly monitoring blood glucose levels, the mother can adjust her diet and insulin intake accordingly to maintain optimal blood sugar levels. This helps in reducing the risk of adverse outcomes such as macrosomia and neonatal hypoglycemia. Choice A is incorrect because while a balanced diet is important, focusing solely on high-protein intake may not address the specific needs of gestational diabetes management. Choice C is also important for overall health, but blood glucose monitoring takes precedence in managing gestational diabetes. Choice D is incorrect as monitoring for preterm labor signs is important in pregnancy but is not directly related to managing gestational diabetes.

Correct Answer: D

Rationale: The correct answer is D: Late decelerations in fetal heart rate. Late decelerations indicate uteroplacental insufficiency, where the fetus is not receiving enough oxygen during contractions. This is critical as it can lead to fetal hypoxia and acidosis, posing a risk to the baby's well-being. Early decelerations (C) are generally benign and result from head compression during contractions. Accelerations (A) are a reassuring sign indicating fetal well-being. Decreased variability (B) can be concerning but is not as critical as late decelerations in indicating fetal distress.

Correct Answer: D

Rationale: The correct answer is D because it promotes non-judgmental support for the mother's decision. As a nurse, it is crucial to respect the mother's autonomy and decision-making. Providing resources on breastfeeding benefits (choice A) may come off as pressuring or judgmental. Offering formula samples (choice B) may not align with the mother's choice. Discussing risks of formula feeding (choice C) may create guilt or shame. Supporting the mother's feeding choice without judgment (choice D) encourages a positive and supportive environment for the mother.