A nurse is caring for an 8-year-old child on an inpatient pediatric unit.

Exhibits

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Body System	Findings
Integumentary	Skin feels cool to the touch. Capillary refill 3 seconds in left foot Dressing on left hand shows small amount of moisture through gauze.
Vital Signs	Blood pressure 102/50 mm Hg Temperature 35.8° C (96.4° F) Respiratory rate 20/min
Genitourinary	Output of 25 mL dark amber urine through catheter

Rationale:

• Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: The nurse should follow the ordered transfusion rate and not titrate it based on blood pressure. The priority is to transfuse the blood safely and at the prescribed rate, while monitoring the client's response. Blood pressure will improve as the blood volume is restored.
• Obtain the first unit of packed RBCs from the blood bank: This is necessary to correct the client’s anemia (Hgb 9.1 g/dL, Hct 27%) and address the suspected acute blood loss indicated by positive hemoccult stool and hemodynamic changes.
• Document the blood product transfusion in the client's medical record: Accurate documentation ensures legal compliance, tracks the administration, and records the client’s response, including any adverse events, supporting continuity of care.
• Stay with the client for the first 15 min of the transfusion: Most transfusion reactions occur during the first 15 minutes. Close observation allows for immediate intervention if the client develops fever, hypotension, or other adverse effects.

• Start an IV bolus of lactated Ringer's solution: Lactated Ringer’s contains calcium which can cause clotting in the transfusion line. Using LR can lead to hemolysis or transfusion complications. Only 0.9% sodium chloride should be used for flushing or running alongside blood transfusions.

Rationale:

A. Urine output 20 mL/hr: This urine output is below the recommended minimum of 30 mL/hr and may indicate magnesium toxicity or worsening renal perfusion. It is not a therapeutic effect and requires prompt evaluation.

B. BP 150/92 mm Hg: This blood pressure is still elevated and does not indicate optimal control of preeclampsia. Magnesium sulfate is given to prevent seizures, not primarily to lower blood pressure, so this is not a measure of therapeutic effect.

C. Absence of eclampsia: Magnesium sulfate is administered in preeclampsia to prevent the onset of eclampsia (seizures). The absence of seizure activity indicates that the medication is having its intended therapeutic effect.

D. FHR 116/min: This fetal heart rate is within the normal baseline range of 110–160/min, but it is not a direct therapeutic effect of magnesium sulfate. It is more a reflection of fetal well-being rather than the drug’s primary purpose.