A nurse is caring for a client who is in active labor and is receiving oxytocin via IV infusion. The nurse has applied an internal fetal heart monitor and recognizes an early deceleration of the fetal heart rate tracing. Which of the following actions should the nurse take?

Choice A rationale:
Increased fetal movement is a positive sign during pregnancy and indicates the well-being of the baby. It is not a concern and does not require reporting.

Choice B rationale:
Increased urinary output may be expected in a client receiving magnesium sulfate due to its diuretic effects. This finding is not alarming and does not require immediate reporting unless it is associated with other concerning symptoms.

Choice C rationale:
Increased muscle weakness is a potential side effect of magnesium sulfate administration. It is important to monitor the client for signs of magnesium toxicity, and increased muscle weakness should be reported promptly as it may indicate the need for adjustments in the dosage or administration of the medication.

Choice D rationale:
Increased respiratory rate is not typically associated with magnesium sulfate use and is unlikely to be a concerning finding in this context. However, it's always essential to monitor respiratory status, but it may not be specifically related to the magnesium sulfate treatment.

Choice A rationale:

Decreasing the maintenance IV solution infusion rate is not the appropriate action for addressing late decelerations of the fetal heart rate. Late decelerations are a concerning sign during labor, indicating possible fetal distress. This can be caused by inadequate oxygenation of the fetus, and reducing IV fluids would not directly address this issue.

Choice B rationale:

Placing the client in a lateral (side-lying) position is the correct action when late decelerations are observed. This position helps to improve uteroplacental blood flow and can relieve pressure on the inferior vena cava, thus increasing oxygen supply to the fetus.

Choice C rationale:

Administering oxygen via face mask at 2 L/min is not the priority action in response to late decelerations. While oxygen may be beneficial in certain situations, it is not the initial intervention for addressing fetal heart rate decelerations.

Choice D rationale:

Administering misoprostol 25 mcg vaginally is not appropriate for addressing late decelerations. Misoprostol is a medication used for cervical ripening and induction of labor, but it does not directly address fetal heart rate changes.