A nurse is assisting with the care of a client who presents to a labor and delivery unit with rapidly progressing labor. Which of the following actions is the priority for the nurse to take?

The correct answer is choice A: Respiratory rate of 16/min.

Choice A rationale:

A respiratory rate of 16/min is within the normal range for adults, which is typically between 12 to 20 breaths per minute. In the context of severe preeclampsia, maintaining a normal respiratory rate is crucial when administering magnesium sulfate IV, as one of the signs of magnesium toxicity is respiratory depression. Therefore, a respiratory rate of 16/min indicates that the client is not experiencing respiratory depression and it is safe to continue the magnesium sulfate infusion.

Choice B rationale:

A heart rate of 60/min is at the lower end of the normal range, which is 60 to 100 beats per minute for adults. However, bradycardia or a low heart rate can be a sign of magnesium sulfate toxicity, especially if accompanied by other symptoms such as hypotension or altered mental status. Without additional context, a heart rate of 60/min alone does not necessarily indicate it is unsafe to continue the infusion, but it would require further assessment.

Choice C rationale:

A urine output of 50 mL in 4 hours is significantly below the expected minimum of 30 mL/hour for adults. Adequate urine output is an important indicator of kidney function and is essential for the excretion of magnesium. In the case of magnesium sulfate infusion for severe preeclampsia, a low urine output could indicate renal insufficiency and an increased risk of magnesium toxicity. Therefore, a urine output of 50 mL in 4 hours is a contraindication for continuing the infusion without further evaluation.

Choice D rationale:

Diminished deep-tendon reflexes can be a sign of magnesium toxicity. Deep-tendon reflexes are assessed to monitor for signs of magnesium overdose during infusion, as magnesium acts as a central nervous system depressant at high levels. If deep-tendon reflexes are diminished, it may suggest that the serum magnesium levels are too high, and the infusion should be paused or discontinued to prevent further toxicity.

In summary, the only finding that clearly indicates it is safe to continue the magnesium sulfate infusion is a normal respiratory rate, as provided in choice A. The other options either require further assessment or are indicators of potential magnesium toxicity.

Choice A rationale:

Visual disturbances should be reported to the provider because the client is experiencing headaches, blurred vision, and dizziness, which can be signs of preeclampsia. Preeclampsia is a serious condition that can develop during pregnancy and is characterized by high blood pressure and damage to organs like the liver and kidneys. Visual disturbances may indicate neurological involvement and can pose a risk to both the client and the fetus.

Choice B rationale:

Blood pressure should be reported to the provider due to the client's symptoms and medical history. The client's weight gain, swelling of feet and fingers, and 2+ pitting edema suggest fluid retention, which can be associated with preeclampsia. High blood pressure is a key diagnostic criterion for preeclampsia, and the nurse must monitor it closely to assess the severity of the condition and the potential risk to both the client and the fetus.

Choice C rationale:

Respirations do not appear to be a significant concern based on the information provided. While respiratory status is important to monitor during pregnancy, there are no indications in the scenario to suggest respiratory distress or abnormalities that require immediate reporting to the provider.

Choice D rationale:

Deep tendon reflexes are mentioned in the client's medical history but do not show any immediate signs of concern. Absent clonus and 3+ deep tendon reflexes are within the normal range and not typically alarming during pregnancy. However, the nurse should continue to monitor these reflexes during subsequent visits.

Choice E rationale:

Weight gain is mentioned in the medical history but is not currently a critical finding to report. A 6 lb weight gain over 2 weeks may be considered appropriate for a pregnant client at 32 weeks of gestation, but it should be assessed in conjunction with other symptoms for a comprehensive evaluation.