A nurse is administering magnesium sulfate to a client at 34 weeks' gestation. What is the priority nursing action for this client?

A nurse is administering magnesium sulfate to a client at 34 weeks' gestation. What is the priority nursing action for this client?

• A. Assess for signs and symptoms of labor.
• B. Assess the client's temperature every 2 hours.
• C. Schedule a daily ultrasound to assess fetal movement.
• D. Schedule a nonstress test every 4 hours to assess fetal well-being.

Answer: (A)

Magnesium sulfate given to delay preterm labor is a tocolytic, so the primary nursing focus is on whether contractions are stopping or if labor is progressing. Assessing for signs of labor—regular, frequent contractions, increasing uterine firmness, changes in cervical dilation, or membrane rupture—tells you whether the tocolytic is working and whether delivery may be imminent. This direct information drives the plan of care and timely decisions about continuing tocolysis or preparing for delivery. Other actions listed are part of routine or adjunct monitoring, but they don’t address the immediate priority of whether labor is being inhibited. Also, stay alert for magnesium toxicity signs (such as diminished reflexes, respiratory depression, or decreased urine output) and be prepared to intervene if they appear.

Magnesium sulfate given to delay preterm labor is a tocolytic, so the primary nursing focus is on whether contractions are stopping or if labor is progressing. Assessing for signs of labor—regular, frequent contractions, increasing uterine firmness, changes in cervical dilation, or membrane rupture—tells you whether the tocolytic is working and whether delivery may be imminent. This direct information drives the plan of care and timely decisions about continuing tocolysis or preparing for delivery.

Other actions listed are part of routine or adjunct monitoring, but they don’t address the immediate priority of whether labor is being inhibited. Also, stay alert for magnesium toxicity signs (such as diminished reflexes, respiratory depression, or decreased urine output) and be prepared to intervene if they appear.