A woman in active labor is receiving intravenous magnesium sulfate for the prevention of eclampsia. What maternal assessment finding indicates magnesium toxicity?

Correct Answer: B

Rationale: Magnesium sulfate is used to prevent eclampsia, but it can lead to toxicity if levels become too high. One common sign of magnesium toxicity is increased deep tendon reflexes, also known as hyperreflexia. This occurs because magnesium is a muscle relaxant, and elevated levels can lead to over-relaxation of muscles, causing an exaggerated reflex response. Other signs of magnesium toxicity include respiratory depression, decreased urine output, and cardiac arrest. Therefore, in a woman receiving intravenous magnesium sulfate during labor, an increase in deep tendon reflexes would indicate potential toxicity and require immediate intervention.

Correct Answer: A

Rationale: Pelvic floor dysfunction can contribute to a prolonged second stage of labor by impairing the ability of the woman to effectively push during contractions. This can result in inefficient pushing efforts and slow fetal descent. The nurse should assess for signs and symptoms of pelvic floor dysfunction, such as difficulty controlling bowel movements or urine leakage, as addressing this issue may help improve the progress of labor. Maternal fatigue, fetal macrosomia (larger than average baby size), and uterine hyperstimulation are other factors that can impact labor but are less likely to specifically contribute to ineffective pushing efforts and slow fetal descent in the second stage of labor.

Correct Answer: A

Rationale: Maternal dehydration can contribute to a prolonged latent phase during labor. Dehydration can lead to reduced blood volume and electrolyte imbalances, which can result in ineffective uterine contractions. Without adequate hydration, the uterus may not contract effectively, causing irregular and infrequent contractions. It is important for the nurse to assess the woman's hydration status and encourage her to stay hydrated during labor to help regulate contractions and progress labor.

Correct Answer: B

Rationale: Educating the client about the "baby blues" phenomenon should be prioritized as it is a common occurrence that happens to many women after giving birth. The "baby blues" refer to feelings of sadness, irritability, and tearfulness that many new mothers experience due to hormonal changes and the stress of adjusting to motherhood. By understanding that these feelings are a normal part of the postpartum period and that they usually resolve on their own within a few weeks, the client may feel reassured and supported. Providing information and support can help the client cope with these emotions and reduce any anxiety or distress they may be feeling. If the client's emotional state does not improve or becomes more severe, further intervention such as referring to a mental health professional may be necessary. But initially, education and reassurance about the "baby blues" can be an effective nursing intervention to address the client's emotional well-being.

Correct Answer: A

Rationale: Educating the client about the importance of balanced nutrition and frequent monitoring of blood glucose levels should be prioritized to address the client's concerns about managing blood sugar levels while breastfeeding. This intervention helps empower the client to make informed choices about her diet and monitor her blood sugar levels effectively. By focusing on balanced nutrition and regular blood glucose monitoring, the client can better manage her blood sugar levels during the postpartum period and while breastfeeding, reducing the risk of complications associated with gestational diabetes. It also promotes overall health and well-being for both the mother and the baby.