A nurse is assessing a client who has a grade 2 placental abruption.
Which of the following findings should the nurse expect?

Answer is: Oral temperature 38.3° C (101° F)

This client is at 30 weeks’ gestation and presenting in preterm labor with uterine contractions, cervical change, and leakage of amniotic fluid. Her vital signs are mostly within normal limits for pregnancy, except for the elevated temperature of 38.3° C, which indicates maternal fever. Fever in a client with preterm labor is concerning because it may suggest intra-amniotic infection (chorioamnionitis), which increases risk for maternal sepsis, fetal infection, and preterm birth complications.

Other vital signs are within normal physiological ranges for pregnancy:

• Heart rate 98/min (slightly elevated but can be normal in pregnancy)
• Respiratory rate 18/min (normal)
• Blood pressure 112/59 mm Hg (normal)
• SaO₂ 98% on room air (normal)

Take-home point: In preterm labor, a maternal fever is a key warning sign that warrants prompt evaluation and interventions to prevent complications for both mother and fetus.

Choice A rationale: Calcium gluconate must be readily available whenever magnesium sulfate is administered because it serves as the antidote for magnesium toxicity. Magnesium sulfate depresses neuromuscular transmission and the central nervous system, which can lead to respiratory depression, hypotension, and cardiac arrest if serum levels become excessive. Having calcium gluconate on hand allows for immediate reversal of these life-threatening effects. This is a critical safety measure and therefore a required nursing action.

Choice B rationale: Respiratory status must be assessed at least every hour during magnesium sulfate therapy because respiratory depression is a primary sign of magnesium toxicity. Normal adult respiratory rate is 12 to 20 breaths per minute, and a rate below 12/min is concerning. Magnesium depresses the respiratory center in the medulla, and early recognition of hypoventilation is essential to prevent hypoxia and arrest. Thus, frequent respiratory monitoring is a priority nursing action.

Choice C rationale: Monitoring intake and output is essential because magnesium sulfate is excreted almost entirely by the kidneys. Oliguria, defined as urine output less than 30 mL/hr, increases the risk of magnesium accumulation and toxicity. Careful fluid balance assessment ensures adequate renal clearance and helps prevent complications such as pulmonary edema. Therefore, strict I&O monitoring is a critical nursing responsibility during magnesium sulfate therapy to ensure safe drug metabolism and excretion.

Choice D rationale: Intermittent fetal monitoring is not appropriate in this context. Magnesium sulfate administration and preterm labor with rupture of membranes require continuous fetal monitoring to detect early signs of distress. Intermittent monitoring risks missing decelerations or prolonged bradycardia. Continuous monitoring provides real-time assessment of fetal well-being and is the standard of care in high-risk obstetric situations. Therefore, intermittent monitoring is not a correct action and should not be selected.

Choice E rationale: Supine positioning is contraindicated in pregnancy, especially in the third trimester, because the gravid uterus compresses the inferior vena cava, leading to supine hypotensive syndrome. This decreases venous return, cardiac output, and uteroplacental perfusion, compromising both maternal and fetal oxygenation. The correct position is left lateral recumbent to optimize circulation. Therefore, placing the client supine is unsafe and not an appropriate nursing action in this scenario.