A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

Explanation:

A. Evaluate neurologic status every 8 hr.

While monitoring neurologic status is important in clients with severe gestational hypertension to assess for signs of impending eclampsia (seizures), more frequent monitoring is typically required, such as every 4 hours or even more frequently depending on the severity of the condition. Therefore, evaluating neurologic status every 8 hours is not sufficient for this client.

B. Provide a dark, quiet environment.

Creating a calm and low-stimulation environment helps to reduce the risk of seizures, which can be triggered by bright lights and loud noises in clients with severe gestational hypertension.

C. Administer magnesium sulfate IV.

Magnesium sulfate is commonly used to prevent seizures in clients with severe gestational hypertension (preeclampsia). It is a standard treatment to prevent eclampsia, a serious complication of preeclampsia characterized by seizures. Therefore, the nurse should expect to administer magnesium sulfate IV as part of the management plan for severe gestational hypertension.

D. Ensure that calcium gluconate is readily available.

Magnesium sulfate, while effective in preventing seizures, can lead to magnesium toxicity if levels become too high. Calcium gluconate is the antidote for magnesium sulfate toxicity. Therefore, the nurse should ensure that calcium gluconate is readily available to counteract any potential magnesium toxicity that may occur during magnesium sulfate administration.

E. Assess respiratory status every 4 hr.

Monitor and record vital signs (blood pressure, pulse, respirations, O2 saturation) every 1 hour x’s 8 hours after maintenance infusion is started and vital signs for bolus infusion are complete. If respiratory rate < 12 breaths/min, draw magnesium level, notify HCP, and observe closely.