A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

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.

Explanation:

A. "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy."

This statement is correct. Around 12 weeks of pregnancy, the baby's heartbeat becomes audible using a Doppler stethoscope. This is a significant milestone in prenatal care as it allows healthcare providers and expectant parents to hear the baby's heartbeat for the first time, providing reassurance about fetal well-being.

B. "Very fine hairs, called lanugo, cover your baby's entire body by week 36 of pregnancy."

This statement is incorrect. Lanugo, the fine hair covering the baby's body, typically appears much earlier in pregnancy, around 20 weeks. However, it usually starts to shed during the third trimester, and by week 36, the baby may have minimal or no lanugo remaining. Therefore, stating that lanugo covers the entire body by week 36 is inaccurate.

C. "The sex of the baby is determined by week 8 of pregnancy."

This statement is incorrect. The sex of the baby is determined at conception when the sperm fertilizes the egg. However, the external genitalia are not typically visible on ultrasound until around week 16 to 20 of pregnancy. Therefore, while the genetic sex is determined early, it may not be visualized or confirmed until later in pregnancy.

D. "You will first feel your baby move in week 24 of pregnancy."

This statement is incorrect. Most women begin to feel fetal movements, also known as quickening, between weeks 16 and 25 of pregnancy. The first movements are typically felt around weeks 18 to 20, rather than specifically at week 24. Therefore, stating that the first fetal movements are felt at week 24 is not accurate.