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Difficulty: MediumPharmacological and Parenteral Therapies

A nurse is caring for a client at 34 weeks gestation who is receiving a continuous intravenous infusion of magnesium sulfate for severe preeclampsia. Which of the following nursing actions are appropriate to ensure safe administration and monitor for medication toxicity? Select all that apply.

  1. Assess the client's deep tendon reflexes (DTRs) every hour.Answer
  2. Ensure that calcium gluconate is readily available at the client's bedside.Answer
  3. Monitor the client's urine output to ensure it remains at or above 30 mL/hr.Answer
  4. D
    Delegate the hourly measurement of blood pressure and respiratory rate to the unlicensed assistive personnel (UAP).
  5. E
    Maintain the client in a strict supine position to maximize placental perfusion.
  6. F
    Administer the infusion through a dedicated total parenteral nutrition (TPN) central line port to minimize venipunctures.

Answer

The appropriate actions are assessing deep tendon reflexes hourly, ensuring calcium gluconate is available at the bedside, and monitoring urine output to ensure it is at least 30 mL/hr.
Magnesium sulfate is a high-alert parenteral medication used to prevent seizures in severe preeclampsia. Safe administration requires meticulous monitoring for signs of toxicity, which include diminished or absent deep tendon reflexes and respiratory depression. Because magnesium is primarily excreted by the kidneys, maintaining adequate urine output (at least 30 mL/hr) is critical to prevent dangerous accumulation of the drug. Additionally, calcium gluconate is the specific antidote for magnesium toxicity and must be kept immediately available to reverse severe respiratory or cardiac depression if toxicity occurs.

Step-by-Step Solution

1
Identify the medication and its primary clinical risks.
Magnesium sulfate is a central nervous system depressant used to prevent seizures in preeclampsia, but it carries a high risk for respiratory and cardiac toxicity.
Understanding the drug's physiological effects dictates the required nursing assessments and safety protocols.
2
Determine the early indicators of toxicity and how the drug is cleared from the body.
Loss of deep tendon reflexes is an early sign of toxicity, and the drug is cleared renally (low urine output increases toxicity risk).
Direct RN monitoring of these specific parameters is necessary to detect dangerous accumulation before respiratory collapse occurs.
3
Evaluate general parenteral safety and delegation protocols.
The antidote (calcium gluconate) must be present, incompatible lines (like TPN) cannot be used, and assessing unstable clients cannot be delegated to a UAP.
Strict adherence to administration rules prevents potentially fatal adverse events associated with high-alert medications.

Key Concept

Safe Administration and Monitoring of Intravenous Magnesium Sulfate
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Topics

Pharmacological and Parenteral Therapies

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