The nurse assessing a postpartum client's fundus finds it firm, 2 centimeters above the umbilicus and displaced to the right.
What is the most appropriate nursing intervention at this time?

Choice A rationale

A reactive nonstress test demonstrates at least two accelerations in fetal heart rate, defined as an increase of 15 beats per minute above the baseline lasting for 15 seconds, within a 20-minute period. These accelerations indicate adequate fetal oxygenation and a healthy fetal autonomic nervous system response to movement.

Choice B rationale

Drawing blood to evaluate the baby's risk of genetic problems is typically performed through procedures like amniocentesis or chorionic villus sampling, not during a nonstress test. A nonstress test assesses fetal well-being based on heart rate patterns in response to fetal movement.

Choice C rationale

While fetal movement is an indicator of fetal well-being, the nonstress test specifically evaluates the fetal heart rate response to that movement. The number of movements within a specific time frame is a component of a biophysical profile, not the sole indicator in a nonstress test.

Choice D rationale

Ultrasound is used to visualize fetal anatomy and assess for congenital anomalies, which is a component of a fetal anatomy scan typically performed around 18-20 weeks of gestation. A nonstress test primarily monitors fetal heart rate and its reactivity.

Choice A rationale

Pain in the abdomen, shoulder, or back can be associated with pre-term labor or other pregnancy complications and should be assessed. However, respiratory depression, hypotension, and absent tendon reflexes are more indicative of magnesium sulfate toxicity and pose an immediate threat to the client's safety.

Choice B rationale

Magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and tocolysis in pre-term labor. Respiratory depression (respiratory rate less than 12 breaths per minute), hypotension (systolic blood pressure less than 90 mmHg or a significant drop from baseline), and absent deep tendon reflexes are signs of magnesium toxicity and require immediate intervention to prevent serious adverse effects.

Choice C rationale

Severe lower back pain, leg cramps, and sweating can be symptoms of pre-term labor or other musculoskeletal issues during pregnancy. While important to assess and manage, they do not represent the same immediate life-threatening risk as magnesium toxicity.

Choice D rationale

Low potassium or elevated glucose levels, tachycardia, and chest pain are not typical side effects of magnesium sulfate. These findings could indicate other underlying medical conditions that need investigation, but they are not the priority assessment related to magnesium sulfate administration compared to signs of toxicity. Normal potassium range is 3.5-5.0 mEq/L, normal fasting glucose is 70-100 mg/dL.