A client is being treated with magnesium sulfate IV. The client’s respiratory rate is 10/min. What should the nurse do?

Choice A Reason:

Turning on the apnea and cardiorespiratory monitor is important for continuous monitoring of the newborn’s vital signs. However, it is not the immediate priority. The newborn’s low Apgar scores indicate severe distress, and immediate resuscitation efforts are necessary to stabilize the infant.

Choice B Reason:

Connecting the resuscitation bag to oxygen is the priority action. The newborn’s Apgar scores of 1 and 4 suggest significant respiratory and cardiovascular compromise. Providing oxygen and assisting with ventilation are critical to ensure adequate oxygenation and perfusion, which are essential for the infant’s survival.

Choice C Reason:

Setting up the radiant warmer control temperature at 36.4°C (97.5°F) is important for maintaining the newborn’s body temperature. However, this is not the immediate priority. Stabilizing the newborn’s respiratory and cardiovascular status takes precedence over temperature regulation.

Choice D Reason:

Preparing for the insertion of an intravenous (IV) line with D5W is necessary for administering fluids and medications. However, it is not the immediate priority. Ensuring the newborn’s airway, breathing, and circulation are stable is the first step in neonatal resuscitation.

Choice A reason:

Assessing maternal blood glucose is important in various clinical scenarios, such as managing diabetes during pregnancy. However, it is not directly related to the immediate issue of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min is a critical sign that requires immediate intervention to prevent further complications.

Choice B reason:

Discontinuing the magnesium infusion is the priority intervention. Magnesium sulfate toxicity can lead to severe respiratory depression, hypotension, and loss of deep tendon reflexes. A respiratory rate of 10/min indicates significant respiratory depression, which can be life-threatening. Stopping the infusion immediately helps to prevent further accumulation of magnesium in the body and allows for the administration of the antidote, calcium gluconate, if necessary.

Choice C reason:

Preparing for an emergency cesarean birth is a critical intervention in cases of fetal distress or other obstetric emergencies. However, in this scenario, the immediate concern is the client’s respiratory depression due to magnesium sulfate toxicity. Addressing the respiratory issue takes precedence to stabilize the client before considering any surgical interventions.

Choice D reason:

Placing the client in Trendelenburg position is typically used to treat hypotension or shock by promoting venous return to the heart. While it can be beneficial in certain situations, it does not address the primary issue of respiratory depression caused by magnesium sulfate toxicity. The priority is to discontinue the magnesium infusion and manage the respiratory depression.