The client at 25 weeks gestation in preterm labor has developed pre-eclampsia.
After receiving Nifedipine to stop her contractions, she is started on magnesium sulfate to control her pre-eclampsia.
When assessing the client, which findings by the nurse indicate that the client is experiencing an adverse effect from the magnesium sulfate? (Select all that apply).

A. Administer antihypertensive medication as prescribed - The client's blood pressure is elevated, and managing hypertension is crucial to prevent complications.

B. Initiate continuous fetal monitoring - The client is experiencing symptoms that could indicate preeclampsia, and continuous monitoring is essential to assess fetal well-being.

C. Monitor for signs of magnesium toxicity - Given the client's symptoms and lab results, monitoring for magnesium toxicity is important, especially if magnesium sulfate is being used for seizure prophylaxis.

D. Perform a vaginal exam to assess cervical status - This intervention is not a priority at this moment given the client's condition and the need to avoid unnecessary interventions that could cause stress or complications.

E. Assess for signs of placental abruption - Although the client denies vaginal bleeding, it's important to monitor for any signs of placental abruption due to her symptoms and hypertension.

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.