A nurse is assisting with the care of a client who has a prescription for magnesium sulfate.Which of the following adverse effects should the nurse report to the provider?

1. Encourage frequent ambulation - Anticipated
   • Ambulation can help progress labor and is generally encouraged if there are no contraindications.
2. Ensure the client maintains a supine position while in bed - Contraindicated
   • Supine positioning can decrease uteroplacental blood flow and is generally not recommended during labor.
3. Check FHR every 30 min - Anticipated
   • Regular monitoring of the fetal heart rate is essential to assess fetal well-being during labor.
4. Perform a Nitrazine test - Anticipated
   • Since the client reports a gush of fluid, a Nitrazine test can help confirm whether the membranes have ruptured.
5. Prepare the client for catheterization - Nonessential
   • The client has voided recently and doesn’t indicate difficulty, making catheterization unnecessary at this stage.
6. Obtain CBC blood sample - Anticipated
   • A CBC can provide important information about the client's health status and identify any potential issues, like infection or anemia.
7. Check the client's temperature every hour - Anticipated
   • Regularly monitoring temperature can help detect signs of infection, which is particularly important if the membranes have ruptured.

Choice A rationale

Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.

Choice B rationale

A temperature of 37.8° C (100° F) is a common finding postpartum and usually does not require intervention unless it is accompanied by other signs of infection.

Choice C rationale

Deep tendon reflexes 2+ is a normal finding and does not require intervention. It indicates normal neuromuscular function.

Choice D rationale

A moderate amount of lochia rubra is expected postpartum and does not require intervention unless it is excessive or associated with other abnormal symptoms.