A nurse is collecting data from a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus. For which of the following data should the nurse monitor?

The correct answer is choice D. Uterine contraction lasting 2 min.

Choice A rationale:

Early decelerations in the FHR are usually not a concern during the second stage of labor. They are a normal physiological response to the compression of the fetal head during contractions and are generally considered benign.

Choice B rationale:

Pelvic pressure with contractions is a normal finding during the second stage of labor as the baby descends into the pelvis. It does not typically require reporting to the provider unless it is associated with other concerning symptoms.

Choice C rationale:

A bloody show from the vagina is a common and expected finding during the second stage of labor. It indicates that the cervix is dilating and effacing, which is a normal part of the labor process.

Choice D rationale:

A uterine contraction lasting 2 minutes is abnormal and could indicate uterine tachysystole, which can lead to fetal distress due to reduced uterine blood flow and oxygen to the fetus. This finding should be reported to the provider immediately.

The correct answer is choice A: Respiratory rate of 16/min.

Choice A rationale:

A respiratory rate of 16/min is within the normal range for adults, which is typically between 12 to 20 breaths per minute. In the context of severe preeclampsia, maintaining a normal respiratory rate is crucial when administering magnesium sulfate IV, as one of the signs of magnesium toxicity is respiratory depression. Therefore, a respiratory rate of 16/min indicates that the client is not experiencing respiratory depression and it is safe to continue the magnesium sulfate infusion.

Choice B rationale:

A heart rate of 60/min is at the lower end of the normal range, which is 60 to 100 beats per minute for adults. However, bradycardia or a low heart rate can be a sign of magnesium sulfate toxicity, especially if accompanied by other symptoms such as hypotension or altered mental status. Without additional context, a heart rate of 60/min alone does not necessarily indicate it is unsafe to continue the infusion, but it would require further assessment.

Choice C rationale:

A urine output of 50 mL in 4 hours is significantly below the expected minimum of 30 mL/hour for adults. Adequate urine output is an important indicator of kidney function and is essential for the excretion of magnesium. In the case of magnesium sulfate infusion for severe preeclampsia, a low urine output could indicate renal insufficiency and an increased risk of magnesium toxicity. Therefore, a urine output of 50 mL in 4 hours is a contraindication for continuing the infusion without further evaluation.

Choice D rationale:

Diminished deep-tendon reflexes can be a sign of magnesium toxicity. Deep-tendon reflexes are assessed to monitor for signs of magnesium overdose during infusion, as magnesium acts as a central nervous system depressant at high levels. If deep-tendon reflexes are diminished, it may suggest that the serum magnesium levels are too high, and the infusion should be paused or discontinued to prevent further toxicity.

In summary, the only finding that clearly indicates it is safe to continue the magnesium sulfate infusion is a normal respiratory rate, as provided in choice A. The other options either require further assessment or are indicators of potential magnesium toxicity.