The nurse is in the process of admitting a multiparous woman to labor and delivery from the triage area.
One hour ago her vaginal exam was 5 cm dilated, 50% effaced, 1+ station.
While completing your review of her prenatal record and completing the admission Questionnaire, she tells you she has an urge to have a bowel movement.
The priority nursing intervention is to:

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.

Choice A rationale

Reassuring the client and rapidly completing the admission does not address the urgent symptom of an urge to have a bowel movement, which can indicate imminent delivery. Immediate assessment of labor progress is necessary.

Choice B rationale

Assisting the client to the bathroom to have a bowel movement may not be appropriate because the urge to defecate can signify the onset of the second stage of labor (pushing stage). Moving to the bathroom could risk an unattended delivery.

Choice C rationale

Assessing the fetal heart rate and uterine contractions with a routine tracing is important, but it does not directly address the urgent symptom of the urge to have a bowel movement. Vaginal exam takes priority to assess labor progress.

Choice D rationale

Assessing her progress of labor with a vaginal exam is the priority because the urge to have a bowel movement can signify that the baby is descending in the birth canal. This is the most immediate and necessary action to determine if delivery is imminent.