A nurse is assessing a client who is 24 weeks pregnant and has preeclampsia.

Which of the following findings should the nurse report to the provider as a manifestation of severe preeclampsia?

Respiratory rate of 10 breaths/min.

This is a sign ofmagnesium toxicity, which can occur when a client receives magnesium sulfate infusion for severe pre-eclampsia.Magnesium toxicity can causemuscle weakness,difficulty breathing,irregular heartbeats, andcardiac arrest.

Choice B is wrong because deep tendon reflexes of 2+ are normal and do not indicate magnesium toxicity.

Choice C is wrong because urine output of 40 mL/hour is adequate and does not indicate magnesium toxicity.

The minimum urine output for an adult is 30 mL/hour.

Choice D is wrong because serum magnesium level of 6 mEq/L is within the normal range of 1.7 to 2.3 mEq/L and does not indicate magnesium toxicity.Magnesium levels above 2.6 mEq/L can indicate hypermagnesemia.

The correct answer is d. Notify the health care provider.

Rationale for Choice A:

• Increasing the rate of oxytocin infusion is contraindicated in this situation.
• Oxytocin stimulates uterine contractions,and the client is already experiencing excessively frequent and prolonged contractions.
• Increased oxytocin could further compromise uteroplacental blood flow and exacerbate fetal distress.
• It could also put the client at higher risk for uterine rupture,a serious complication associated with oxytocin use.

Rationale for Choice B:

• While administering oxygen is a common intervention for fetal distress,it's not the priority action in this case.
• Late decelerations in fetal heart rate are typically caused by uteroplacental insufficiency,which means the fetus isn't receiving adequate oxygen and nutrients from the placenta.
• Oxygen administered to the mother may not significantly improve fetal oxygenation if the underlying issue is impaired placental perfusion.

Rationale for Choice C:

• Turning the client to her left side is a recommended position to improve placental blood flow.
• However,in this situation,it's not the priority action given the presence of late decelerations and excessive uterine contractions.
• It may be a helpful adjunct measure,but it won't address the primary cause of fetal distress.

Rationale for Choice D:

• Notifying the health care provider is the most crucial action because:
  • The client has severe pre-eclampsia,a serious condition that requires close monitoring and management.
  • The frequent and prolonged contractions,along with late decelerations in the fetal heart rate,indicate potential fetal distress.
  • The health care provider needs to be aware of these changes to make timely decisions regarding interventions,such as:
    • Adjusting the oxytocin infusion
    • Expediting delivery if necessary
    • Implementing other measures to improve fetal well-being
    • Closely monitoring the mother's condition to prevent complications of pre-eclampsia