A nurse is caring for a client who is at 34 weeks of gestation. The client has a medical history of gestational diabetes, preeclampsia with previous pregnancy, and chronic hypertension for 5 years. The client's vital signs are: BP: 170/104 mm Hg, Pulse: 89/min, Respirations: 20/min, Temperature: 98.8°F (37.1°C) Oral, Oxygen saturation: 97% room air. The nurse is reviewing the client's medical record to develop a plan of care.
What are the two most important nursing interventions for this client?

Choice A rationale
This is incorrect because respirations 16/min are within the normal range and do not indicate magnesium toxicity. The nurse should monitor the client's respiratory rate and report any signs of respiratory depression, such as less than 12/min.

Choice B rationale
This is incorrect because fetal heart rate 158/min is within the normal range and does not indicate fetal distress. The nurse should monitor the fetal heart rate and report any signs of bradycardia, tachycardia, or decreased variability.

Choice C rationale
This is incorrect because headache for 30 min is a common symptom of pre-eclampsia and does not indicate magnesium toxicity. The nurse should administer analgesics as prescribed and report any signs of increased intracranial pressure, such as blurred vision, confusion, or seizures.

Choice D rationale
This is correct because urinary output 40 mL in 2 hr is below the expected amount and indicates renal impairment. The nurse should report this finding to the provider and monitor the client's fluid intake and output, serum creatinine, and blood urea nitrogen levels. The nurse should also assess the client for signs of fluid overload, such as edema, crackles, or dyspnea.

Choice A rationale
Monitoring the fetal heart rate and movement is an important nursing intervention for this client. The client is at risk of fetal distress due to the high blood pressure, the preeclampsia, and the gestational diabetes. The fetal heart rate and movement can indicate the fetal well-being and oxygenation. The nurse should monitor the fetal heart rate continuously and perform a nonstress test or a biophysical profile as indicated.

Choice B rationale
Administering magnesium sulfate as prescribed is an important nursing intervention for this client. The client is at risk of seizures due to the severe preeclampsia. Magnesium sulfate is a medication that prevents and treats seizures in preeclamptic clients. The nurse should administer magnesium sulfate as prescribed and monitor the client's vital signs, reflexes, urine output, and magnesium level.

Choice C rationale
Encouraging the client to drink plenty of fluids is not an important nursing intervention for this client. The client is at risk of fluid overload due to the high blood pressure and the preeclampsia. Fluid overload can cause pulmonary edema, heart failure, and cerebral edema in the client. The nurse should restrict the client's fluid intake and monitor the client's weight, edema, and lung sounds.

Choice D rationale
Educating the client about the signs of preterm labor is not an important nursing intervention for this client. The client is at 34 weeks of gestation, which is close to the term pregnancy. The client is more likely to have a planned delivery or an induction of labor due to the high-risk conditions. The nurse should educate the client about the signs of preeclampsia, such as headache, blurred vision, epigastric pain, and decreased urine output.