A nurse is caring for a client who is being admitted to the labor and delivery unit.
Client reports mild abdominal pain and light vaginal bleeding.
Reports last menstrual period was 11 weeks ago.

Choice A rationale

Pain in the abdomen, shoulder, or back can be associated with pre-term labor or other pregnancy complications and should be assessed. However, respiratory depression, hypotension, and absent tendon reflexes are more indicative of magnesium sulfate toxicity and pose an immediate threat to the client's safety.

Choice B rationale

Magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and tocolysis in pre-term labor. Respiratory depression (respiratory rate less than 12 breaths per minute), hypotension (systolic blood pressure less than 90 mmHg or a significant drop from baseline), and absent deep tendon reflexes are signs of magnesium toxicity and require immediate intervention to prevent serious adverse effects.

Choice C rationale

Severe lower back pain, leg cramps, and sweating can be symptoms of pre-term labor or other musculoskeletal issues during pregnancy. While important to assess and manage, they do not represent the same immediate life-threatening risk as magnesium toxicity.

Choice D rationale

Low potassium or elevated glucose levels, tachycardia, and chest pain are not typical side effects of magnesium sulfate. These findings could indicate other underlying medical conditions that need investigation, but they are not the priority assessment related to magnesium sulfate administration compared to signs of toxicity. Normal potassium range is 3.5-5.0 mEq/L, normal fasting glucose is 70-100 mg/dL.

Choice A rationale

When the fetal heart tones are heard loudest in the upper right abdominal quadrant above the umbilicus, it suggests that the fetal back, which transmits sound most clearly, is located in that area. In a breech presentation, the fetal buttocks or feet are in the lower uterine segment, and the head is in the upper portion of the uterus. Therefore, the fetal heart sounds would be best auscultated in the upper abdomen.

Choice B rationale

In the left occiput anterior (LOA) position, the fetal occiput is in the left anterior quadrant of the maternal pelvis. The fetal heart tones are typically heard loudest in the lower left quadrant of the maternal abdomen because the fetal back is usually anterior and slightly to the left.

Choice C rationale

Polyhydramnios is an excessive amount of amniotic fluid. While it can sometimes make it more difficult to auscultate fetal heart tones clearly due to increased fluid volume, it does not directly correlate with the location where the heart tones are heard loudest. The position of the fetus is the primary determinant of the auscultation location.

Choice D rationale

In the right occiput posterior (ROP) position, the fetal occiput is in the right posterior quadrant of the maternal pelvis. The fetal heart tones would typically be heard loudest in the lower right quadrant of the maternal abdomen, as the fetal back would be positioned posteriorly and to the right.