A nurse is caring for a client who is in the first stage of labor.
The nurse observes the umbilical cord protruding from the vagina.
Which of the following actions should the nurse NOT perform?

Choice A rationale

Reassuring the patient that she will deliver vaginally is inappropriate and could be misleading, especially if there are complications such as placental abruption or severe pre-eclampsia, which may necessitate a cesarean delivery for the safety of the mother and baby.

Choice B rationale

Inserting an indwelling Foley catheter is a standard procedure to monitor urine output and kidney function, especially in cases of pre-eclampsia, where accurate monitoring of fluid balance is crucial.

Choice C rationale

Initiating IV therapy with Lactated Ringer's solution is important to maintain maternal hydration and electrolyte balance, especially if the client is experiencing blood loss and is at risk of hypovolemia.

Choice D rationale

Monitoring the fetal heart tracing is essential to assess the baby's well-being. Continuous fetal monitoring helps detect signs of fetal distress, allowing for timely interventions to ensure the safety of both mother and baby.

Choice A rationale

Respiratory rate of 8 breaths per minute indicates respiratory depression, a serious adverse effect of magnesium sulfate toxicity. Magnesium sulfate can depress neuromuscular transmission, leading to decreased respiratory effort and rate.

Choice B rationale

Blood pressure of 150/90 mmHg is not indicative of magnesium sulfate toxicity. Elevated blood pressure is a symptom of pre-eclampsia and not directly related to the adverse effects of magnesium sulfate. Therefore, it does not indicate toxicity.

Choice C rationale

Lung crackles are typically associated with fluid overload or heart failure rather than magnesium sulfate toxicity. While it is a serious condition, it is not specifically an adverse effect of magnesium sulfate.

Choice D rationale

Increase in fetal heart rate is not a common adverse effect of magnesium sulfate. Fetal heart rate changes are more commonly related to the underlying maternal condition or other medications used in pregnancy rather than magnesium sulfate.

Choice E rationale

Deep tendon reflexes would typically be decreased or absent in magnesium sulfate toxicity. Therefore, presence of deep tendon reflexes would not indicate an adverse effect of magnesium sulfate.

Choice F rationale

Confusion can occur due to central nervous system depression caused by high levels of magnesium sulfate. This is a significant adverse effect indicating possible toxicity.

Choice G rationale

Urine output of 30 mL in 2 hours suggests oliguria, which can be a sign of magnesium sulfate toxicity as the drug is excreted through the kidneys. Reduced urine output can indicate the kidneys are not clearing the drug efficiently, leading to toxicity.