A nurse is assessing a client with severe pre-eclampsia who is receiving magnesium sulfate infusion.

Which finding should alert the nurse to suspect magnesium toxicity?

Epigastric pain and nausea.This is because epigastric pain and nausea are signs of severe preeclampsia that indicate liver involvement and possible hepatic rupture.

This is a medical emergency that requires immediate intervention to prevent maternal and fetal complications.

Choice A is wrong because contractions lasting 90 seconds and occurring every 2 minutes are normal during labor induction with oxytocin and do not indicate severe preeclampsia.

Choice B is wrong because fetal heart rate baseline of 140/min with moderate variability is a reassuring sign of fetal well-being and does not indicate severe preeclampsia.

Choice C is wrong because cervical dilation of 4 cm and effacement of 50% are normal findings during labor induction and do not indicate severe preeclampsia.

The correct answer is choice A and C. A client with HELLP syndrome is at risk for bleeding, liver damage, and fluid overload or transfusion reaction.Therefore, the nurse should monitor vital signs and urine output to assess for signs of shock, hemorrhage, or renal failure.The nurse should also check for signs of fluid overload or transfusion reaction such as dyspnea, crackles, edema, fever, chills, or rash.

Choice B is wrong because corticosteroids are not indicated for clients with HELLP syndrome unless they have severe thrombocytopenia or need to delay delivery for fetal lung maturity.Corticosteroids may worsen the liver function and increase the risk of infection.

Choice D is wrong because encouraging oral intake of fluids and electrolytes may exacerbate fluid overload and hypertension in clients with HELLP syndrome.Fluid restriction and diuretics may be prescribed to reduce the risk of pulmonary edema and cerebral edema.

Choice E is wrong because maintaining bed rest and a quiet environment may not be sufficient to prevent the progression of HELLP syndrome.The definitive treatment for HELLP syndrome is delivery of the fetus and placenta as soon as possible.Bed rest and a quiet environment may help reduce blood pressure and stress, but they are not the main interventions for this condition.