A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours
On assessment the nurse finds the following vital signs: temperature of 37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus. The client complains, "I'm so thirsty and warm." The nurse:
a. Calls for a stat magnesium sulfate level.
b. Administers oxygen.
c. Discontinues the magnesium sulfate infusion.
d. Prepares to administer hydralazine.
ANS: C
The client is displaying clinical signs and symptoms of magnesium toxicity. Magnesium should be discontinued immediately. In addition, calcium gluconate, the antidote for magnesium, may be administered. Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP greater than 160 mm Hg or a diastolic BP greater than 110 mm Hg.
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