67. A client, who is gravida 1, para 0 with severe preeclampsia, has been on a magnesium sulfate infusion at 2 gm/hr for the past 6 hours. Her recent assessment reveals a blood pressure 150/88 mm Hg, pulse 88, respirations 16, 1+ deep tendon reflexes, with 80 mL of urinary output during the past hour. Which action should a nurse take?
. Decrease the infusion rate to 1 gm/hr and turn the client on her left side.
. Continue the infusion of magnesium sulfate and monitor the client's blood pressure.
. Stop the infusion of magnesium sulfate and notify the physician.
. Administer calcium gluconate IV push and notify the physician.
Test-Taking Tip
This question is asking if the client is having symptoms consistent with magnesium toxicity. Since the client has a normal assessment, there is no need for intervention.
Content Area: Maternity, Antepartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Expected Effects/Outcomes
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Answer 1 is incorrect because the assessment is normal for this client; there is no reason to decrease the infusion. Decreasing the magnesium level may put the client at risk for eclampsia. Answer 2 is correct because the assessment findings are normal for this client; continuing the infusion is the appropriate action for the nurse. Answer 3 is incorrect because the assessment is normal for this client; there is no reason to stop the infusion. Decreasing the magnesium level may put the client at risk for eclampsia. Answer 4 is incorrect because the assessment is normal for this client; there is no reason to administer an antidote to the client. Decreasing the magnesium level may put the client at risk for eclampsia.