A nurse is completing an 8-hr 1&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

A) Urinary output 40 mL in 2 hr:
A urinary output of 40 mL in 2 hours is significantly low and could indicate decreased renal perfusion, which may be a sign of magnesium sulfate toxicity. Therefore, the nurse should report this finding to the provider promptly.

B) Fetal heart rate 158/min:
A fetal heart rate of 158/min is within the normal range for a fetus and is not directly related to the client's magnesium sulfate therapy. This finding does not require immediate reporting.

C) Headache for 30 min:
While headaches can be a symptom of preeclampsia, in this case, the headache is mild and of short duration. It may not necessarily indicate a complication related to magnesium sulfate therapy. However, it should be monitored, but it does not require immediate reporting.

D) Respirations 16/min:
A respiratory rate of 16/min is within the normal range for an adult and is not indicative of magnesium sulfate toxicity. This finding does not require immediate reporting.

C) Position the client on her side:
Late decelerations indicate uteroplacental insufficiency, which could compromise fetal oxygenation. The priority nursing action is to reposition the client on her side to alleviate pressure on the vena cava and improve placental blood flow. Side-lying position, particularly the left lateral position, can enhance placental perfusion and alleviate pressure on the vena cava, thus improving fetal oxygenation.

A) Elevate the client's legs:
Elevating the client's legs is not the priority action for addressing late decelerations. While it might be beneficial in some situations, the immediate priority is to reposition the client to improve uteroplacental perfusion.

B) Increase the infusion rate of the IV fluid:
Increasing the infusion rate of IV fluid is not the priority action for addressing late decelerations. While ensuring adequate hydration is important during labor, the priority is to reposition the client to improve uteroplacental perfusion.

D) Administer oxygen via face mask:
Administering oxygen via face mask is an appropriate intervention for fetal distress; however, repositioning the client to alleviate late decelerations takes precedence. If late decelerations persist after repositioning, then providing oxygen therapy would be the next appropriate action.