A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take?

Rationale for correct choices

• Stop the magnesium sulfate infusion: The client exhibits signs of magnesium sulfate toxicity, including lethargy, shallow respirations, hyporeflexia (DTR 1+), and oliguria (urine output 20 mL/hr). Immediate cessation of the infusion is the priority to prevent progression to respiratory depression, coma, or cardiac arrest. Stopping the infusion reduces further magnesium accumulation and stabilizes the client.

• Calcium gluconate: Calcium gluconate is the antidote for magnesium sulfate toxicity. It counteracts the neuromuscular and cardiac effects of magnesium, reversing hyporeflexia and respiratory depression. The nurse should prepare calcium gluconate IV for rapid administration while monitoring vital signs and respiratory status closely.

Rationale for incorrect choices

• Apply oxygen via nasal cannula: Although supplemental oxygen can support the client’s respiratory function, it does not reverse the toxic effects of magnesium. Oxygen therapy alone is insufficient in managing magnesium toxicity and is secondary to stopping the infusion.

• Place the client in Trendelenburg position: Trendelenburg positioning is not indicated and may worsen respiratory compromise. Maintaining a side-lying or semi-Fowler’s position is safer for airway management and monitoring during magnesium toxicity.

• Magnesium sulfate: Continuing magnesium sulfate would worsen toxicity, potentially leading to respiratory failure, cardiac arrest, and further CNS depression. Administration is contraindicated once toxicity signs appear.

• IV antibiotics: There is no indication of infection or sepsis in the client’s current assessment. Antibiotics do not address magnesium toxicity and are not warranted at this stage.

A. A history of gastroesophageal reflux disease: GERD increases the likelihood of gastric contents refluxing into the esophagus and potentially being aspirated into the lungs. Clients receiving enteral feedings with impaired lower esophageal sphincter function are at higher risk for aspiration pneumonia, making this a significant risk factor.

B. Receiving a high-osmolarity formula: High-osmolarity formulas may cause gastrointestinal discomfort, diarrhea, or delayed gastric emptying, but they do not directly increase aspiration risk if proper feeding techniques and positioning are used.

C. A residual of 65 mL 1-hr postprandial: A small gastric residual of 65 mL is generally considered within acceptable limits and does not significantly increase aspiration risk. High residuals (e.g., >250 mL) are more concerning.

D. Sitting in high-Fowler's position during the feeding: Maintaining a high-Fowler’s position (60–90°) during enteral feeding reduces aspiration risk by promoting gastric emptying and minimizing reflux. This positioning is protective rather than a risk factor.