A nurse at an antepartum clinic is admitting a client who is at 30 weeks of gestation. Exhibits Which of the following actions should the nurse take after administering the prescribed medications? Select all that apply.

A. Keep calcium gluconate readily available: Magnesium sulfate can cause toxicity, including respiratory depression and cardiac arrest. Calcium gluconate is the antidote and must be available at the bedside in case of adverse effects. This is a critical safety measure during therapy. B. Urinary output should be monitored hourly, not every 2 hours, because magnesium is excreted by the kidneys. Reduced urine output can quickly lead to magnesium accumulation and toxicity, so frequent monitoring is essential. C. Check deep tendon reflexes every 1 hr: Loss of deep tendon reflexes is an early sign of magnesium toxicity. Hourly assessments help detect neuromuscular depression and guide dosage adjustments. Reflex monitoring is essential during magnesium infusion. D. Provide intermittent fetal monitoring: This is inappropriate in the context of severe hypertension and magnesium sulfate administration. Continuous fetal monitoring is required to assess fetal well-being and detect signs of distress, especially in a high-risk situation. E. Report respiratory rate of less than 12 breaths/min to the provider: Respiratory depression is a major sign of magnesium toxicity. A respiratory rate below 12 indicates central nervous system depression and requires immediate attention. Prompt reporting allows timely intervention to prevent complications.