The patient has been on IV magnesium sulfate for severe preeclampsia for 24 hours. On assessment, the nurse finds the following vital signs: temperature of 37.3 C, HR 88, RR 9. B/P 140/90, absent deep tendon reflexes, and no ankle clonus. The patient complains, "I am so thirsty and warm," and seems lethargic. The nurse's first action is to:

A. Occiput anterior position. The occiput anterior (OA) position is the ideal fetal position for vaginal delivery, where the baby’s head is well-engaged in the pelvis. This positioning reduces the risk of a prolapsed cord since the presenting part (the fetal head) effectively blocks the cord from slipping through.

B. Breech presentation. In a breech presentation, the buttocks or feet are the presenting part, leaving more space in the birth canal. This increases the risk of cord prolapse, especially if the feet or buttocks do not fully block the cervix, allowing the umbilical cord to slip past and become compressed.

C. Cervical dilation 5 cm. While cervical dilation is important in labor progression, it does not directly increase the risk of cord prolapse. The risk is more dependent on fetal position and station rather than the degree of cervical dilation.

D. Station -4. A high fetal station (e.g., -4) means the baby’s presenting part has not yet descended into the pelvis, leaving more room for the umbilical cord to slip through once the membranes rupture. A well-engaged fetus at station 0 or lower helps prevent prolapse by blocking the cervix.

A. Insert an internal fetal scalp electrode monitor. There is no indication for an internal fetal monitor, as the external monitoring shows a reassuring fetal heart rate pattern with moderate variability and no decelerations. Internal monitoring is typically used when external monitoring is inadequate or when fetal distress is suspected.

B. Contact the doctor at once and reposition the patient. There is no fetal distress or abnormal contraction pattern requiring immediate physician intervention. The fetal heart rate is within the normal range (110-160 bpm), and moderate variability indicates adequate oxygenation.

C. Document the finding in the patient's medical record. This is the correct action because the assessment findings indicate a well-oxygenated fetus and a normal labor progression. Contractions every 3-4 minutes lasting 60 seconds are within the expected range for oxytocin augmentation, and no abnormalities are present.

D. Discontinue the IV fluid containing Pitocin (oxytocin). There is no need to stop the oxytocin infusion, as the contraction pattern is appropriate, and there are no signs of uterine tachysystole or fetal distress.