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

High blood glucose levels in early pregnancy increase the risk of congenital heart defects in the baby.

Choice B rationale

Hip dysplasia is not directly associated with maternal diabetes but can be a congenital condition regardless of maternal glucose control.

Choice C rationale

Necrotizing enterocolitis is more related to prematurity and not directly linked to maternal diabetes.

Choice D rationale

Port wine stains are vascular birthmarks and are not associated with maternal blood glucose levels. .

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.