A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?

Correct Answer: C

Rationale: The correct answer is C: Monitor the FHR continuously. This is essential in preeclampsia as magnesium sulfate can affect fetal heart rate (FHR). Continuous monitoring helps detect any changes promptly. A: Monitoring blood pressure is important but not as critical as FHR monitoring in this scenario. B: Restricting total hourly intake to 200 mL is not necessary for magnesium sulfate administration. D: Administering protamine sulfate is incorrect as it is used for heparin toxicity, not magnesium sulfate toxicity.

Correct Answer: D

Rationale: The correct answer is D: Place the newborn skin-to-skin on the mother's chest. This technique promotes bonding, warmth, and comfort, which can help minimize the newborn's pain perception during the procedure. Skin-to-skin contact releases oxytocin, which has analgesic effects. It also provides emotional support and reduces stress for both the newborn and the mother. A, applying a cool pack, may cause vasoconstriction and increase pain perception. B, requesting an IM analgesic, is not typically necessary for a routine heel stick and may have potential adverse effects. C, using a manual lancet, does not address the emotional and psychological aspects of pain perception in newborns.

Correct Answer: A

Rationale: The correct answer is A. Late decelerations indicate fetal distress, suggesting compromised oxygenation. Starting oxytocin can further stress the fetus, worsening decelerations. Report to prevent harm. B is incorrect as moderate variability is a reassuring sign of fetal well-being. C is incorrect as cessation of uterine dilation may indicate uterine hyperstimulation, not fetal distress. D is incorrect as prolonged active labor phase alone doesn't necessarily contraindicate oxytocin, but it may require monitoring.

Correct Answer: C

Rationale: The correct answer is C: Weight gain of 2.2 kg (4.8 lb). This finding should be reported to the provider because sudden excessive weight gain in late pregnancy can be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. This could indicate a potential complication that needs immediate medical attention. Explanation: A: Blood pressure 136/88 mm Hg - This blood pressure reading is slightly elevated but not concerning for preeclampsia at this level. B: Report of insomnia - Insomnia is a common issue during pregnancy and not typically a cause for immediate concern. D: Report of Braxton-Hicks contractions - Braxton-Hicks contractions are common in the third trimester and are considered normal as long as they are not regular or increasing in intensity.

Correct Answer: D

Rationale: The correct answer is D: Monitor the fetal heart rate (FHR). After an amniocentesis, the priority is monitoring FHR to assess fetal well-being and detect any signs of distress. This is crucial as the procedure carries a risk of causing fetal distress. Checking the client's temperature (A) is important but not the priority. Observing for uterine contractions (B) is important but not immediate post-amniocentesis. Administering Rho(D) immune globulin (C) is typically done in cases of Rh incompatibility and not directly related to the amniocentesis procedure.