A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patient's magnesium level is 7.6 mg/dL
What is the nurse's priority action?
a. Stop the infusion of magnesium.
b. Assess the patient's respiratory rate.
c. Assess the patient's deep tendon reflexes.
d. Notify the health care provider of the magnesium level.
ANS: B
The therapeutic serum level for magnesium is 4 to 8 mg/dL although it is elevated in terms of normal lab values. Adverse reactions to magnesium sulfate usually occur if the serum level becomes too high. The most important is CNS depression, including depression of the respiratory center. Magnesium is excreted solely by the kidneys, and the reduced urine output that often occurs in preeclampsia allows magnesium to accumulate to toxic levels in the woman. Frequent assessment of serum magnesium levels, deep tendon reflexes, respiratory rate, and oxygen saturation can identify CNS depression before it progresses to respiratory depression or cardiac dysfunction. Monitoring urine output identifies oliguria that would allow magnesium to accumulate and reach excessive levels. Discontinue magnesium if the respiratory rate is below 12 breaths/min, a low pulse oximeter level (<95%) persists, or deep tendon reflexes are absent. Additional magnesium will make the condition worse.
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