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Difficulty: MediumPharmacological and Parenteral Therapies

A client at 35 weeks gestation is receiving a continuous intravenous (IV) infusion of magnesium sulfate for the management of severe preeclampsia. During an hourly assessment, the nurse notes the client is difficult to arouse, has a respiratory rate of 10 breaths/minute10\text{ breaths/minute}, and deep tendon reflexes are absent. Which of the following is the priority nursing action?

  1. Discontinue the magnesium sulfate infusion immediately and prepare to administer calcium gluconate.Answer
  2. B
    Decrease the magnesium sulfate infusion rate by half and apply oxygen via nasal cannula.
  3. C
    Administer the prescribed calcium gluconate through the existing IV line while the magnesium sulfate continues to infuse.
  4. D
    Administer 10% calcium gluconate by rapid intravenous push over 15 seconds to quickly reverse the depression.

Answer

The priority action is to immediately discontinue the magnesium sulfate infusion and prepare to administer the antidote, calcium gluconate.
The client is exhibiting signs of severe magnesium sulfate toxicity, specifically a respiratory rate below 12 breaths/minute12\text{ breaths/minute}, absent deep tendon reflexes, and a decreased level of consciousness. The absolute highest priority action is to stop the continuous infusion immediately to prevent progression to respiratory or cardiac arrest. Once the infusion is stopped, the nurse prepares the antidote, calcium gluconate.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has lethargy, a respiratory rate of 10 breaths/minute, and absent deep tendon reflexes.
These are classic, life-threatening indicators of magnesium sulfate toxicity.
2
Determine the highest priority intervention based on the clinical findings.
The continuous infusion must be stopped.
When an infused medication causes acute toxicity, the immediate physiological priority is to remove the source of the harm before attempting to reverse its effects.
3
Identify the correct protocol for administering the antidote.
Calcium gluconate must be prepared for slow IV administration in a flushed or separate IV line.
Rapid push of calcium gluconate causes cardiac complications, and pushing it through an actively infusing toxic line delivers a lethal bolus.

Key Concept

Management of Magnesium Sulfate Toxicity
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Topics

Pharmacological and Parenteral Therapies

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