A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following findings is the nurse's priority?

A. 2+ deep-tendon reflexes: This is a normal reflex response and indicates that magnesium levels are not excessively high. Diminished or absent reflexes would be a more concerning sign of toxicity.
B. Respiratory rate 10/min: A respiratory rate below 12/min suggests respiratory depression, which is a serious adverse effect of magnesium sulfate toxicity. This is the priority finding requiring immediate intervention.
C. Urinary output 35 mL/hr: This is slightly above the minimum expected output of 30 mL/hr. While renal function must be monitored to prevent magnesium accumulation, this rate is adequate for now.
D. Pedal edema: Edema is common in preeclampsia and is not an urgent concern compared to signs of magnesium toxicity such as respiratory depression.

Rationale for Correct Answer:

• Falls due to genitourinary assessment findings: The client reports urinary frequency and urgency, and the urinalysis reveals positive nitrites and leukocyte esterase, indicating a urinary tract infection (UTI). These symptoms can increase nighttime bathroom trips and rushing to void, both of which raise fall risk, especially in hospitalized or postpartum clients.

Rationale for Incorrect Choices:

• Impaired nutrition due to genitourinary assessment findings: There are no signs of inadequate intake, weight loss, or gastrointestinal symptoms. The client has a normal appetite and no vomiting or diarrhea, and the UTI is unrelated to nutritional deficits.
• Pressure injuries due to blood pressure findings: The client’s blood pressure is within acceptable limits for adults and does not suggest hypoperfusion or immobility-related risk. Additionally, no skin issues or limited mobility were reported.
• Falls due to mobility findings: While falls are possible with impaired mobility, the nurse noted that the client has a steady gait, indicating that mobility is intact and not contributing to fall risk.