Using Leopold's Maneuvers, the fetus is found to be with its occiput facing toward the left maternal spine.
The mother is complaining of increased back labor pain.
The nurse knows that the fetus is in which position?

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.

Rationale for correct condition: The client presents with a history of chronic hypertension, headache, visual disturbances, upper abdominal discomfort, and elevated blood pressure. Diagnostic results show elevated uric acid, proteinuria, and decreased platelet count. Physical examination reveals facial swelling, trace pitting edema, and hyperreflexia with clonus. These findings indicate preeclampsia, a condition of elevated blood pressure and proteinuria after 20 weeks of gestation. Preeclampsia may lead to severe complications if untreated.

Rationale for actions:

• Administering magnesium sulfate helps prevent seizures associated with severe preeclampsia.
• Preparing for immediate delivery is necessary if preeclampsia poses a severe risk to the mother or fetus.

Rationale for parameters:

• Monitoring blood pressure trends is crucial to manage and prevent severe hypertensive complications.
• Checking platelet count helps detect worsening coagulopathy, which is common in preeclampsia.

Rationale for incorrect conditions:

• Gestational hypertension: It lacks proteinuria and does not fully account for symptoms like severe headache and visual disturbances.
• HELLP syndrome: Although it shares similarities, HELLP would present with more severe hemolysis and liver involvement.
• Placental abruption: This condition would present with vaginal bleeding and abdominal pain, which are not reported in this case.