Pharmacological and Parenteral Therapies Q 84
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?
A. The nurse places a sign over the bed not to check blood pressure in the right arm.
B. The nurse places a padded tongue blade at the bedside.
C. The nurse inserts a Foley catheter.
D. The nurse darkens the room.
Correct Answer: C. The nurse inserts a Foley catheter.
The client receiving magnesium sulfate should have a Foley catheter in place, and hourly intake and output should be checked. Strict intake and output will be assessed throughout the magnesium sulfate infusion. Record urinary output at least every 1 hour if Foley catheter is in place. Otherwise, measure and record all voids. Urine output should be at least 30 mL/hour while administering magnesium sulfate. If less, notify the provider of decreased urine output.
Option A: There is no need to refrain from checking the blood pressure in the right arm. Before beginning any infusion of magnesium sulfate, the primary RN will obtain baseline vital signs (temperature, pulse, respirations, blood pressure, and O2 saturation). Baseline fetal heart rate (FHR), deep tendon reflexes (DTRs), clonus, bilateral breath sounds, urinary output, and activity will be assessed and documented in the Electronic Health Record (EHR).
Option B: A padded tongue blade should be kept in the room at the bedside, just in case of a seizure, but this is not related to the magnesium sulfate infusion. Temperature is assessed every 4 hours, unless rupture of membranes. Once membranes have ruptured, temperature will be assessed every 2 hours. If febrile (? 100.4) provider will be notified and temperature will be assessed hourly thereafter.
Option D: Darkening the room is unnecessary. Inform staff and visitors of the need to maintain a quiet environment, and avoidance of excessive visitation and environmental stimulation. Include assessment of epigastric pain, visual disturbances, edema, headache, level of consciousness, and lung auscultation prior to start of infusion and every 2 hours throughout infusion or more frequently as condition indicates.