Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
46. A nurse is preparing to administer intravenous magnesium sulfate to a client diagnosed with preeclampsia. Which action should the nurse take when administering this medication?
. Administer a solution of 20 gm magnesium sulfate in 100 mL of lactated Ringer's solution.
. Monitor maternal VS, FHR, and uterine contractions every hour.
. Expect the maintenance dose to be approximately 4 gm/hr.
. Discontinue the infusion and notify the physician of a respiratory rate of <12 breaths/min.
Test-Taking Tip
Magnesium is a central nervous system depressant and can cause respiratory failure at a toxic level. Watch the respiratory rate closely.
Content Area: Maternity, Antepartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Parenteral/Intravenous Therapies
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because this is the wrong concentration of magnesium sulfate. The usual concentration is 40 gm of magnesium sulfate in 1,000 mL of lactated Ringer's solution. Answer 2 is incorrect because, although monitoring vital signs are an important part of every nursing assessment for a client in labor, this client is being treated for preeclampsia, for which the vital signs need to be assessed more frequently than every hour. Answer 3 is incorrect because the maintenance dose should be approximately 2 gm/hr. The loading dose is usually 4 gm over a 30-minute period. Answer 4 is correct because a respiratory rate of less than 12 breaths/min can be a result of magnesium toxicity. The nurse should discontinue the infusion and notify the physician.