Which assessments are included in the fetal biophysical profile (BPP)? (Select all that apply.)

Choice A reason: A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions does not need to be reported to the provider immediately, because it may indicate preterm labor, which is not an emergency. The nurse should assess the client's cervix, fetal heart rate, and hydration status, and administer tocolytic therapy as prescribed.

Choice B reason: A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes does not need to be reported to the provider immediately, because they are expected findings in mild preeclampsia. The nurse should monitor the client's blood pressure, urine output, and reflexes, and administer antihypertensive and anticonvulsant medications as prescribed.

Choice C reason: A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache needs to be reported to the provider immediately, because they are signs of severe preeclampsia or impending eclampsia. The nurse should prepare the client for delivery, as it is the only definitive treatment for preeclampsia.

Choice D reason: A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors does not need to be reported to the provider immediately, because they are a common and mild side effect of terbutaline, a beta-adrenergic agonist that relaxes the uterine smooth muscle. The nurse should reassure the client that the tremors are temporary and harmless, and monitor the client's pulse and blood pressure.

Choice A reason: To call for an immediate magnesium sulfate level is not the immediate action that the nurse should take, as it is a diagnostic test that requires a blood sample and a laboratory analysis, which can take time and delay the treatment. The nurse should first stop the infusion and notify the provider, as the client is showing signs of magnesium sulfate toxicity, which is a life-threatening condition that can cause respiratory depression, cardiac arrest, or coma.

Choice B reason: To prepare to administer hydralazine is not the immediate action that the nurse should take, as it is a pharmacological intervention that requires a prescription and an assessment of the blood pressure and the fetal status. Hydralazine is an antihypertensive drug that lowers the blood pressure and prevents the complications of severe preeclampsia, such as eclampsia, stroke, or organ damage. However, the client's blood pressure is not very high and is not the main problem at the moment.

Choice C reason: To discontinue the magnesium sulfate infusion is the immediate action that the nurse should take, as it is the first and most important intervention that can reverse the effects of magnesium sulfate and restore the neuromuscular function and the respiratory rate. Magnesium sulfate is a drug that prevents seizures and lowers the blood pressure in clients with severe preeclampsia, but it can also cause toxicity if the dose is too high or the infusion is too fast.

Choice D reason: To administer oxygen is not the immediate action that the nurse should take, as it is a supportive intervention that improves the oxygen delivery to the tissues and organs, but does not address the underlying cause of the respiratory depression, which is the magnesium sulfate toxicity. The nurse should administer oxygen only after stopping the infusion and assessing the oxygen saturation and the respiratory status.