A nurse is caring for a client who is receiving magnesium sulfate for pre-term labor.

Which of the following assessments should the nurse perform to evaluate the therapeutic effect of the medication?

Assess fetal heart rate and activity.

The nurse should identify that a client who reports a sudden gush of fluid from her vagina is at risk forpremature rupture of membranes (PROM), which can lead toinfection,cord prolapse, andfetal distress.Therefore, the priority action is to assess the fetal heart rate and activity to monitor for signs of hypoxia or distress.

Choice B is wrong because performing a nitrazine test on the fluid is not the first action.A nitrazine test can confirm the presence of amniotic fluid by detecting its alkaline pH, but it is not as urgent as assessing the fetal well-being.

Choice C is wrong because administering oxytocin (Pitocin) IV infusion is contraindicated in this situation.Oxytocin is used to induce or augment labor, but it can causeuterine hyperstimulation,fetal distress, andplacental abruptionif given to a client who has PROM.

Choice D is wrong because placing the client in Trendelenburg position is not recommended for a client who has PROM.Trendelenburg position can increase the risk ofcord prolapseandaspirationin this situation.

All of the above.The nurse should include all of these signs and symptoms in the teaching as they may indicate pre-term labor.Pre-term labor occurs when regular contractions begin to open the cervix before 37 weeks of pregnancy.

Choice A is wrong because decreased fetal movement is not a normal sign of pre-term labor, but it may indicate fetal distress or other complications.

Choice B is wrong because increased vaginal discharge is not a normal sign of pre-term labor, but it may indicate infection or rupture of membranes.

Choice C is wrong because pelvic pressure is not a normal sign of pre-term labor, but it may indicate cervical dilation or descent of the fetus.