A nurse is performing a nonstress test on a client who is at 35 weeks of gestation and has diabetes mellitus. The test reveals no accelerations of fetal heart rate for 20 min. Which of the following actions should the nurse take?

Choice A rationale:

The Moro reflex, also known as the startle reflex, is elicited by making a loud noise above the newborn, causing them to extend their arms and legs and then bringing them back to the body in a hugging motion. This reflex is a normal developmental response in term newborns.

Choice B rationale:
Touching the newborn's cheek with a finger elicits the rooting reflex, where the newborn turns their head toward the stimulus, searching for a nipple or object to suck. It is a different reflex and not the Moro reflex.

Choice C rationale:
Tapping the newborn's forehead with a finger does not elicit any specific reflex. This action is not related to the Moro reflex.

Choice D rationale:
Turning the newborn's head to one side elicits the asymmetric tonic neck reflex (ATNR), not the Moro reflex. In ATNR, when the head is turned to one side, the arm on that side extends while the opposite arm flexes.

Choice A rationale:

This manifestation, urine output of 20 mL/hr, is an adverse reaction to magnesium sulfate administration. Magnesium sulfate can lead to decreased urine output, and it is essential for the nurse to monitor the client's urinary output closely. Low urine output may indicate decreased kidney function, which can be a sign of magnesium toxicity.

Choice B rationale:

Hypertension is expected in a client with preeclampsia, and magnesium sulfate is used to help manage and prevent seizures in these cases. While it is essential to monitor and manage hypertension during pregnancy, it is not considered an adverse reaction to magnesium sulfate.

Choice C rationale:

Hyperglycemia is not a common adverse reaction to magnesium sulfate. Magnesium sulfate may cause central nervous system depression, muscle weakness, and respiratory depression, but it does not typically cause hyperglycemia.

Choice D rationale:

A respiratory rate of 16/min is within the normal range for an adult and is not indicative of an adverse reaction to magnesium sulfate. Magnesium sulfate can cause respiratory depression at higher doses, but a respiratory rate of 16/min does not raise immediate concerns.