What will be an ideal response?
A 26-year-old patient with preeclampsia is receiving IV magnesium sulfate. The 1400 assessment includes blood pressure, 100/70 mm Hg; respiration, 10; fetal heart tone, 100/min; urine output, 20 mL/hr; and absent patellar reflex
Which is the priority nursing action?
a. Decrease IV magnesium sulfate to half the dose and reassess the patient and fetus in 15 minutes.
b. Stop the IV magnesium sulfate and contact the health care provider.
c. Place the patient on her left side and administer oxygen.
d. Stop the IV magnesium sulfate and administer calcium gluconate 5 mEq IV over 3 minutes.
ANS: D
The patient is exhibiting signs of magnesium sulfate toxicity, including respiratory depression. The infusion should be stopped at once. The antidote, calcium gluconate, should be administered.
Nursing
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