A nurse is educating a pregnant client about the differences between Braxton Hicks contractions and true labor contractions.
Which statement should the nurse include?

Choice A rationale

While fetal heart rate (FHR) is a crucial assessment in preterm labor, especially when considering the effects of medications, it is not the immediate priority assessment before initiating magnesium sulfate. Magnesium sulfate primarily affects the mother's central nervous system and neuromuscular system.

Choice B rationale

Respiratory rate is the priority nursing assessment before administering magnesium sulfate. Magnesium sulfate is a central nervous system depressant and can cause respiratory depression, a potentially life-threatening side effect. Establishing a baseline respiratory rate and ensuring it is within the normal range (12-20 breaths per minute for adults) is critical before administering the medication.

Choice C rationale

Temperature is an important vital sign to monitor, but it is not the priority assessment before administering magnesium sulfate. Magnesium sulfate does not typically have a direct impact on body temperature. Other assessments related to the medication's effects take precedence. Normal adult temperature range is typically 97.8°F to 99.1°F (36.5°C to 37.3°C).

Choice D rationale

Bowel sounds are an assessment related to gastrointestinal function and are not the priority assessment before administering magnesium sulfate. While magnesium sulfate can have some effects on smooth muscle, including the intestines, the immediate risk of respiratory depression necessitates prioritizing respiratory assessment. Normal bowel sounds are typically described as normoactive, with clicks and gurgles occurring irregularly.

Choice A rationale

Preterm labor is defined as labor that occurs between 20 and 37 weeks of gestation. The patient is already at 37 weeks' gestation, so preterm labor is not a complication to prevent.

Choice B rationale

Gestational diabetes is glucose intolerance that develops during pregnancy. While elevated blood pressure can sometimes be associated with gestational diabetes, magnesium sulfate is not a primary treatment or preventative measure for this condition. Management typically involves dietary changes, exercise, and sometimes insulin.

Choice C rationale

Magnesium sulfate is commonly administered in the setting of preeclampsia with severe features or eclampsia to prevent seizures. The patient's consistently elevated blood pressure readings (above 160/110 mmHg on multiple occasions) indicate severe hypertension, a key diagnostic criterion for preeclampsia with severe features, placing her at high risk for seizures (eclampsia). Magnesium sulfate acts as a central nervous system depressant, reducing neuronal excitability and thus the risk of seizures.

Choice D rationale

Fetal growth restriction (FGR) is a condition where the fetus does not grow at the expected rate in utero. While severe preeclampsia can contribute to FGR due to placental insufficiency, magnesium sulfate is not directly used to prevent fetal growth restriction. The primary focus of magnesium sulfate in this scenario is maternal seizure prophylaxis.