A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

A client who is in labor and reports an urge to have a bowel movement during contractions may be experiencing the transition phase of labor, which is the last and most intense part of the first stage of labor¹². The transition phase occurs when the cervix dilates from 8 to 10 cm and the baby descends into the birth canal¹². The pressure of the baby's head on the rectum can cause a sensation of needing to defecate¹². The transition phase can last from 15 minutes to an hour or more, and it can be accompanied by other signs, such as strong, regular, and painful contractions lasting 60 to 90 seconds; increased bloody show; nausea and vomiting; shaking and shivering; and emotional changes such as irritability, anxiety, or excitement¹²³.
The nurse should reassess the client who reports an urge to have a bowel movement during contractions because this may indicate that the client is close to delivering the baby and needs to be prepared for the second stage of labor, which involves pushing and giving birth¹². The nurse should check the client's cervical dilation, fetal heart rate, and maternal vital signs, and notify the provider if the client is fully dilated or shows signs of fetal or maternal distress¹². The nurse should also support the client's coping strategies, such as breathing techniques, relaxation methods, or pain relief options, and encourage the client not to push until instructed by the provider¹².

b) A sense of excitement and warm, flushed skin are not signs that require reassessment by the nurse. These are normal emotional and physiological responses to labor that reflect increased adrenaline levels and blood flow¹⁴. They do not indicate any complications or imminent delivery.
c) Progressive sacral discomfort during contractions is not a sign that requires reassessment by the nurse. This is a common symptom of labor that results from the pressure of the baby's head on the sacrum and nerves in the lower back¹⁴. It does not indicate any problems or imminent delivery.
d) Intense contractions lasting 45 to 60 seconds are not signs that require reassessment by the nurse. These are typical characteristics of active labor contractions, which occur when the cervix dilates from 4 to 8 cm¹⁴. They do not indicate any complications or imminent delivery.

Magnesium sulfate is a medication that is used to prevent seizures in women with preeclampsia, a condition that causes high blood pressure and organ damage during pregnancy. It is given intravenously (through a vein) and can also help lower blood pressure and relax the uterus¹.

Magnesium sulfate can cause various side effects and complications, such as
- Nausea, vomiting, or diarrhea
- Headache, drowsiness, or confusion
- Flushing, sweating, or feeling hot
- Weakness, muscle twitching, or paralysis
- Low blood pressure or slow heart rate
- Difficulty breathing or respiratory depression
- Allergic reaction or anaphylaxis
One of the serious complications of magnesium sulfate is magnesium toxicity, which occurs when the level of magnesium in the blood becomes too high. Magnesium toxicity can affect the nervous system, the muscles, the heart, and the lungs. It can cause severe symptoms, such as:
- Loss of reflexes
- Slurred speech or blurred vision
- Chest pain or cardiac arrest
- Coma or death
Magnesium toxicity can be caused by several factors, such as:
- Overdose of magnesium sulfate
- Impaired kidney function or renal failure
- Dehydration or fluid loss
- Interaction with other medications, such as calcium channel blockers or neuromuscular blockers
One of the signs of magnesium toxicity is decreased urine output. Urine output is a measure of how much urine the kidneys produce and excrete. It reflects the kidney function and hydration status. Normal urine output for adults is about 0.5 to 1 mL/kg/hour. For a 70 kg adult, this would be about 35 to 70 mL/hour².
Decreased urine output can indicate that the kidneys are not working properly and are unable to filter and remove excess magnesium from the blood. This can lead to a buildup of magnesium in the blood and cause magnesium toxicity. Decreased urine output can also indicate that the body is dehydrated and has low blood volume. This can reduce the blood flow to the kidneys and impair their function².
Therefore, the nurse should recognize urine output 20 mL/hr. as an adverse reaction to magnesium sulfate and report it to the provider immediately. The nurse should also monitor the client's vital signs, reflexes, respiratory status, and magnesium level closely and be prepared to administer calcium gluconate as an antidote if needed¹²³.

The other options are not manifestations that the nurse should recognize as adverse reactions to
magnesium sulfate:
- a) Hypertension is not an adverse reaction to magnesium sulfate, but a symptom of preeclampsia. Magnesium sulfate can help lower blood pressure in women with preeclampsia by relaxing the blood vessels and reducing vascular resistance¹³.

- c) Hyperglycemia is not an adverse reaction to magnesium sulfate, but a condition that causes high blood sugar levels. It can be caused by diabetes mellitus, pregnancy-induced diabetes (gestational diabetes), infection, stress, or certain medications. Magnesium sulfate does not affect blood sugar levels directly.
- d) Respiratory rate 16/min is not an adverse reaction to magnesium sulfate, but a normal finding for
respiratory rate in adults. The normal range for respiratory rate in adults is 12 to 20 breaths per minute. The respiratory rate may vary depending on age, activity level, health status, and environmental factors.