A nurse is caring for a client who has severe pre-eclampsia and is receiving hydralazine IV.

Which of the following adverse effects should the nurse monitor for?

Administer calcium gluconate as an antidote if toxicity occurs.Magnesium sulfate is a mineral that reduces seizure risks in women with severe preeclampsia.However, it can also cause side effects and toxicity, such as respiratory depression, muscle weakness, and cardiac arrest.Calcium gluconate is an antidote that can reverse the effects of magnesium sulfate and restore normal neuromuscular function.

Choice B is wrong because magnesium sulfate does not affect blood glucose levels.

There is no need to monitor the client’s blood glucose level every 4 hours.

Choice C is wrong because the infusion should be discontinued if the client’s respiratory rate is below 12/min, not 16/min.

A low respiratory rate indicates respiratory depression, which is a sign of magnesium toxicity.

Choice D is wrong because the infusion rate should not be increased if the client’s urine output is above 30 mL/hr.Urine output should be at least 30 mL/hr while administering magnesium sulfate to prevent accumulation of the drug in the body.

Increasing the infusion rate can increase the risk of toxicity.

The correct answer is d. Notify the health care provider.

Rationale for Choice A:

• Increasing the rate of oxytocin infusion is contraindicated in this situation.
• Oxytocin stimulates uterine contractions,and the client is already experiencing excessively frequent and prolonged contractions.
• Increased oxytocin could further compromise uteroplacental blood flow and exacerbate fetal distress.
• It could also put the client at higher risk for uterine rupture,a serious complication associated with oxytocin use.

Rationale for Choice B:

• While administering oxygen is a common intervention for fetal distress,it's not the priority action in this case.
• Late decelerations in fetal heart rate are typically caused by uteroplacental insufficiency,which means the fetus isn't receiving adequate oxygen and nutrients from the placenta.
• Oxygen administered to the mother may not significantly improve fetal oxygenation if the underlying issue is impaired placental perfusion.

Rationale for Choice C:

• Turning the client to her left side is a recommended position to improve placental blood flow.
• However,in this situation,it's not the priority action given the presence of late decelerations and excessive uterine contractions.
• It may be a helpful adjunct measure,but it won't address the primary cause of fetal distress.

Rationale for Choice D:

• Notifying the health care provider is the most crucial action because:
  • The client has severe pre-eclampsia,a serious condition that requires close monitoring and management.
  • The frequent and prolonged contractions,along with late decelerations in the fetal heart rate,indicate potential fetal distress.
  • The health care provider needs to be aware of these changes to make timely decisions regarding interventions,such as:
    • Adjusting the oxytocin infusion
    • Expediting delivery if necessary
    • Implementing other measures to improve fetal well-being
    • Closely monitoring the mother's condition to prevent complications of pre-eclampsia