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Difficulty: HardPharmacological and Parenteral Therapies

A nurse is evaluating a client at 35 weeks of gestation who is receiving a continuous intravenous infusion of magnesium sulfate for severe preeclampsia. During the hourly assessment, the nurse notes a respiratory rate of 10 breaths/min, absent patellar deep tendon reflexes, and a urine output of 12 mL over the past hour. Which of the following actions should the nurse take? (Select all that apply)

  1. Stop the magnesium sulfate infusion immediately.Answer
  2. Prepare to administer intravenous calcium gluconate.Answer
  3. C
    Administer the prescribed antidote through the existing magnesium sulfate intravenous line.
  4. D
    Delegate the ongoing assessment of the client's respiratory status to the unlicensed assistive personnel.
  5. Ensure a bag-valve-mask resuscitator and emergency equipment are readily available at the bedside.Answer
  6. F
    Increase the primary intravenous fluid rate to promote renal excretion of the medication.

Answer

The correct actions are to stop the magnesium sulfate infusion immediately, prepare to administer intravenous calcium gluconate, and ensure a bag-valve-mask resuscitator and emergency equipment are readily available at the bedside.
The assessment findings of bradypnea (respiratory rate less than 12 breaths/min), absent patellar deep tendon reflexes, and severe oliguria indicate clinical magnesium sulfate toxicity. The immediate priority is to stop the infusion to prevent respiratory or cardiac arrest. Calcium gluconate is the specific pharmacological antidote and must be prepared for intravenous administration. Because the client is exhibiting severe respiratory depression, having a bag-valve-mask resuscitator and emergency equipment at the bedside is critical to support the airway and ventilation.

Step-by-Step Solution

1
Analyze the client's assessment findings.
The client has a respiratory rate of 10 breaths/min, absent deep tendon reflexes, and severe oliguria (12 mL/hr).
These are classic, critical signs of magnesium sulfate toxicity requiring immediate life-saving intervention.
2
Determine the highest priority nursing intervention.
The continuous magnesium sulfate infusion must be stopped immediately.
Removing the source of the toxicity is the first step in the chain of survival to prevent cardiac and respiratory arrest.
3
Identify the necessary pharmacological and supportive treatments.
Prepare calcium gluconate and ensure emergency airway equipment is at the bedside.
Calcium gluconate acts as the direct antidote to magnesium toxicity, and airway equipment is required due to the active respiratory depression.
4
Evaluate the safety of parenteral administration routes and delegation.
Do not mix the antidote with the existing magnesium line, do not aggressively hydrate, and do not delegate assessments.
Magnesium and calcium are incompatible. The client is highly unstable, requiring RN-level care and strict fluid management to prevent pulmonary edema.

Key Concept

Management of Magnesium Sulfate Toxicity and Parenteral Safety
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Topics

Pharmacological and Parenteral Therapies

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