A nurse is caring for a client with gestational hypertension who is at risk for developing preeclampsia.

Which of the following interventions should the nurse implement to prevent this complication? (Select all that apply.).

The correct answer is choice D) Level of consciousness and reflexes.This is because magnesium sulfate can cause toxicity and affect the central nervous system, leading to decreased level of consciousness and loss of reflexes.These are signs that the dose of magnesium sulfate should be reduced or stopped.

The nurse should prioritize assessing these parameters to prevent seizures and avoid magnesium toxicity.

Choice A) Respiratory rate and depth is wrong because magnesium sulfate can also cause respiratory depression, but this is a less common and less sensitive indicator of toxicity than level of consciousness and reflexes.

Choice B) Urine output and color is wrong because magnesium sulfate can also cause renal impairment, but this is not directly related to preventing seizures.However, urine output should be monitored to ensure adequate hydration and renal function.

Choice C) Blood pressure and heart rate is wrong because magnesium sulfate can also cause hypotension and bradycardia, but these are not the primary goals of therapy.Blood pressure and heart rate should be monitored to assess the severity of preeclampsia and the response to antihypertensive medications.

The correct answer is choice D. Have calcium gluconate available at the bedside as an antidote.Magnesium sulfate is used to prevent and treat seizures in women with severe preeclampsia or eclampsia.However, it can also cause toxicity and respiratory depression if the serum level is too high.Calcium gluconate is the antidote for magnesium sulfate toxicity and should be readily available at the bedside.

Choice A is wrong because the medication should be administered over 20-30 minutes using an infusion pump.

A shorter infusion time may increase the risk of adverse effects.

Choice B is wrong because the client should be placed in a lateral position to improve uteroplacental perfusion and reduce the risk of aspiration.

Choice C is wrong because the client’s blood pressure should be monitored every 5 minutes during the infusion, not every 15 minutes.

Blood pressure is an indicator of the severity of preeclampsia and the effectiveness of magnesium sulfate therapy.