A nurse is monitoring a patient who is receiving magnesium sulfate to manage pre-eclampsia.
Which of the following observations should the nurse report to the healthcare provider?

Choice A rationale
A patient at 28 weeks of gestation receiving terbutaline may report fine tremors. This is a common side effect of terbutaline, which is a medication used to relax the muscles in the uterus to prevent premature labor. However, while it may be uncomfortable for the patient, it is not typically a cause for immediate concern.
Choice B rationale
A tearful patient at 32 weeks of gestation experiencing irregular, frequent contractions could be experiencing Braxton Hicks contractions, which are often referred to as “false labor.”. These contractions are usually irregular and do not increase in intensity or frequency. While they can be uncomfortable, they are a normal part of pregnancy and do not typically require immediate medical attention. Choice C rationale
A patient diagnosed with preeclampsia reporting epigastric pain and an unresolved headache should be reported to the healthcare provider immediately. These symptoms could indicate severe preeclampsia, which can lead to serious complications if not treated promptly. Epigastric pain may suggest liver involvement, and a persistent headache could be a sign of neurological involvement, both of which require immediate medical attention.
Choice D rationale
A patient diagnosed with preeclampsia having 2+ proteinuria and 2+ patellar reflexes is expected. Proteinuria is a common symptom of preeclampsia, and hyperreflexia can be a sign of increased neurological excitability, a common feature of preeclampsia. However, these findings alone do not typically require immediate medical attention.

Choice A rationale
Preparing the abdominal and perineal areas is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. This type of bleeding is suggestive of placenta previa, a condition where the placenta covers part or all of the cervix, preventing normal delivery. While preparing the abdominal and perineal areas may be necessary in preparation for delivery, it is not the immediate priority.
Choice B rationale
Initiating IV access is the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. This type of bleeding is suggestive of placenta previa, a condition where the placenta covers part or all of the cervix, preventing normal delivery. IV access allows for rapid administration of fluids and medications, which may be necessary to stabilize the client’s condition.
Choice C rationale
Inserting an indwelling urinary catheter is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. While a urinary catheter may be necessary in preparation for delivery or surgery, it is not the immediate priority.
Choice D rationale
Witnessing the signature for informed consent for surgery is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. While obtaining informed consent may be necessary before performing certain procedures or surgeries, it is not the immediate priority.