A multigravida client at 31 weeks gestation is admitted with confirmed pre-term labor.
As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?

Choice A rationale

Pain in the abdomen, shoulder, or back can be associated with pre-term labor or other pregnancy complications and should be assessed. However, respiratory depression, hypotension, and absent tendon reflexes are more indicative of magnesium sulfate toxicity and pose an immediate threat to the client's safety.

Choice B rationale

Magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and tocolysis in pre-term labor. Respiratory depression (respiratory rate less than 12 breaths per minute), hypotension (systolic blood pressure less than 90 mmHg or a significant drop from baseline), and absent deep tendon reflexes are signs of magnesium toxicity and require immediate intervention to prevent serious adverse effects.

Choice C rationale

Severe lower back pain, leg cramps, and sweating can be symptoms of pre-term labor or other musculoskeletal issues during pregnancy. While important to assess and manage, they do not represent the same immediate life-threatening risk as magnesium toxicity.

Choice D rationale

Low potassium or elevated glucose levels, tachycardia, and chest pain are not typical side effects of magnesium sulfate. These findings could indicate other underlying medical conditions that need investigation, but they are not the priority assessment related to magnesium sulfate administration compared to signs of toxicity. Normal potassium range is 3.5-5.0 mEq/L, normal fasting glucose is 70-100 mg/dL.

Choice A rationale

Methergine (methylergonovine) is an oxytocic medication that causes vasoconstriction and increases blood pressure. It is contraindicated in clients with hypertension. Therefore, assessing the client's blood pressure before administration is crucial to ensure safety. Normal adult blood pressure is typically less than 120/80 mmHg.

Choice B rationale

Assessing uterine tone is important in managing postpartum hemorrhage, as a boggy uterus contributes to bleeding. However, before administering a medication that affects blood pressure, the blood pressure itself is the priority assessment due to the contraindications of Methergine in hypertensive clients.

Choice C rationale

Deep tendon reflexes are assessed in the postpartum period, particularly for clients with preeclampsia who are at risk for magnesium sulfate toxicity. While important, it is not the priority assessment before administering Methergine, which has a direct impact on blood pressure.

Choice D rationale

Assessing the amount of lochia is essential for monitoring postpartum bleeding. However, before administering Methergine, which can significantly increase blood pressure, ensuring the client does not have a contraindication related to hypertension is the most critical immediate assessment. .