A patient at 33 weeks' gestation is admitted to the obstetric unit in active labor with symptoms associated with pregnancy-induced hypertension (PIH). Which action(s) will the nurse implement? (Select all that apply.)
a. Vital signs hourly
b. Administration of IV pitocin
c. Administration of magnesium sulfate IV
d. Fetal stress test
e. Assessment of deep tendon reflexes
ANS: A, C, D, E
Important nursing assessments and/or interventions include monitoring of vital signs and level of consciousness continuously, continuous fetal monitoring with stress tests and external or internal fetal monitoring, and deep tendon reflexes. IV magnesium sulfate is often prescribed for patients with PIH. Oxytocin increases uterine contractions and is contraindicated in preterm labor.
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