A nurse is caring for a client with eclampsia who is having a tonic-clonic seizure.

Which action should the nurse take first?

Stop the magnesium sulfate infusion.

The client is showing signs of magnesium toxicity, such as absent deep tendon reflexes, which can lead to respiratory depression and cardiac arrest.

Magnesium sulfate is an anticonvulsant that is used to prevent seizures in eclampsia, but it can also cause vasodilation and hypotension.

The nurse should stop the infusion and monitor the client’s vital signs and neurological status.

Choice B. Increase the rate of the hydralazine infusion is wrong because hydralazine is an antihypertensive that lowers blood pressure.

The client’s blood pressure is already within the normal range for eclampsia (140/90 to 160/110 mmHg), so increasing the rate of hydralazine could cause hypotension and compromise placental perfusion.

Choice C. Administer calcium gluconate IV push is wrong because calcium gluconate is an antidote for magnesium toxicity, but it should not be given IV push.

It should be given slowly over 10 to 20 minutes to avoid cardiac arrhythmias and bradycardia.

Choice D. Prepare for immediate delivery of the fetus is wrong because delivery of the fetus is not indicated at this time.

The client’s vital signs are stable and there is no evidence of fetal distress or placental abruption.

Delivery of the fetus is the definitive treatment for eclampsia, but it should be done when the maternal and fetal conditions are optimal.

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