[Verified Answer]: The nurse is caring for a client admitted…

The nurse is caring for a client admitted to the labor and delivery unit at 35 weeks gestation with preeclampsia. Admission Note0845. Client is a G1 P0 29-year-old primigravida at 35 weeks gestation admitted with preeclampsia. Plan is admission, diet NPO, magnesium sulfate x 24 hours, followed by induction of labor.FlowsheetTime0900100011001200Magnesium sulfate dose4g2g2g2gReflexes presentYes +3Yes +2Yes +2NoBlood pressure159/89139/84131/85120/76Heart rate727172102Respirations18181711Pulse oximetry99% on RA99% on RA98% on RA92% on RAIV FluidsNS 150mL/hr Mg 100 mL/hrNS 150mL/hr Mg 50 mL/hrNS 150mL/hr Mg 50 mL/hrNS 150mL/hr Mg 100 mL/hrUrine Output35 mL30 mL30 mL20 mLOther drugs or observationsNoneNauseaNausea, cutaneous flushing, sweatingShortness of breath0900. 4g loading dose magnesium sulfate IV started, to be run over 20 minutes. Mainline IV of Normal Saline infusing at 150 mL/hr. Second nurse verified pump settings. Client educated on medication side effects. Client complains of headache rated 7/10, no nausea/vomiting, no epigastric pain, no visual disturbances. Current BP 159/89. Fetal monitor shows baseline heart rate 130 bpm, moderate variability, accelerations present, decelerations absent, no contractions noted. Indwelling catheter placed; draining dark amber urine. 0920. Magnesium sulfate loading dose complete. Magnesium rate changed to 2g/hr continuous infusion. Second nurse verified pump settings. Mainline Normal Saline infusing at 150 mL/hr. 1100. Client noted to have cutaneous flushing and sweating. Client states she is nauseous, negative for vomiting. Fan brought to bedside. 1200. Absent patellar reflex, RR 11, with complaints of shortness of breath. Pulse oximeter 92% on RA. Question at position 5 5 Multiple Answer 3 points Question at position 5 Which 3 actions should the nurse take first? (Select 3) Administer calcium gluconate Draw serum magnesium level Monitor fetus Provide oxygen Stop magnesium infusion Check for medication error Activate rapid response