A nurse is caring for a client diagnosed with preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

Explanation:

A. "I should drink about 2 liters of fluid each day."

This statement is generally accurate and aligned with recommendations for adequate hydration during pregnancy. The recommended daily fluid intake for pregnant individuals is typically around 8 to 10 cups of fluids per day, which is approximately 2 liters. Adequate hydration is important during pregnancy to support overall health, prevent dehydration, and maintain proper functioning of bodily systems.

B. "I can have a moderate amount of caffeine daily."

This statement is generally acceptable and aligned with guidelines from organizations such as the American College of Obstetricians and Gynecologists (ACOG). Moderate caffeine intake, typically defined as up to 200 milligrams per day, is considered safe during pregnancy for most individuals. However, it's essential to be mindful of caffeine sources and consume them in moderation, as excessive caffeine intake can have adverse effects on pregnancy outcomes.

C. "I should not drink alcoholic beverages during my pregnancy."

This statement is correct and crucial for a healthy pregnancy. Alcohol consumption during pregnancy is associated with various risks, including fetal alcohol spectrum disorders (FASDs) and developmental issues. Therefore, healthcare providers universally recommend abstaining from alcohol entirely during pregnancy to protect the health and well-being of both the mother and the developing baby.

D. "I should increase my calcium intake to 1,500 milligrams per day."

This statement indicates a need for clarification because the recommended daily intake of calcium during pregnancy is typically around 1,000 milligrams per day for most pregnant individuals. While some healthcare providers may recommend slightly higher amounts, such as up to 1,300 milligrams per day, a calcium intake of 1,500 milligrams per day is relatively high and may not align with standard recommendations without specific indications such as a history of low calcium levels or certain medical conditions. It's important for the nurse to clarify and provide accurate information regarding appropriate calcium intake during pregnancy based on the client's individual needs.

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.