The nurse is performing an assessment on a client who thinks she may be experiencing preterm labor. Which information is most important for the nurse to understand and share with the client?

A. Betamethasone is a corticosteroid given to enhance fetal lung maturity, typically when preterm birth is anticipated (<34–37 weeks). At 38 weeks gestation, the fetus is term, so corticosteroids are not indicated.

B. Hydralazine is an antihypertensive medication used to treat severe hypertension in pregnancy (systolic ≥160 mm Hg or diastolic ≥110 mm Hg). This client’s BP is 170/112 mm Hg, which meets criteria for immediate pharmacologic intervention to prevent maternal complications such as stroke, eclampsia, or organ damage. Therefore, the nurse should anticipate an order for hydralazine (or another antihypertensive like labetalol or nifedipine) to lower blood pressure safely.

C. Dexamethasone is also a corticosteroid used to promote fetal lung development and is not indicated at term gestation (38 weeks) for this client.

D. Lovenox (enoxaparin) is an anticoagulant used for thromboembolism prevention. While some pregnant clients may require anticoagulation, this client’s primary acute concern is severe hypertension, not clotting risk, making Lovenox inappropriate as the first intervention.

A. While assessing temperature is important for evaluating maternal infection or overall condition, it is not the primary concern when administering magnesium sulfate. Fever does not typically indicate magnesium toxicity, so it is not the priority assessment in this situation.

B. This is the priority assessment because magnesium sulfate can cause respiratory depression if serum levels exceed the therapeutic range. Magnesium acts as a central nervous system depressant and smooth muscle relaxant, which helps inhibit uterine contractions in preterm labor but also poses a risk to respiratory function. The nurse should assess the client’s respiratory rate before initiating the infusion and monitor continuously throughout therapy. A respiratory rate below 12 breaths per minute may indicate early magnesium toxicity, necessitating immediate cessation of the infusion, administration of calcium gluconate as an antidote, and supportive respiratory care.

C. Monitoring blood pressure is important, especially in clients with preeclampsia, because magnesium sulfate can have mild hypotensive effects. However, the most immediate risk of toxicity is respiratory depression, not blood pressure changes. Therefore, while BP is monitored, it is secondary to respiratory assessment in this context.

D. Bowel sounds are part of a routine assessment but are not affected by magnesium sulfate and do not relate to the medication’s most dangerous complications.