A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube.

Which of the following actions should the nurse plan to take?

A. BP 150/92 mm Hg:

• This blood pressure reading is elevated and not a therapeutic effect of magnesium sulfate. In the context of preeclampsia, the goal is usually to lower blood pressure to prevent complications.

B. Pulse rate 100/min:

• The pulse rate of 100/min is not a specific therapeutic effect of magnesium sulfate. However, magnesium sulfate may cause a decrease in heart rate, so monitoring for bradycardia would be important.

C. Flushed face:

• A flushed face is not a specific therapeutic effect of magnesium sulfate. Facial flushing may be associated with other factors, but it is not a primary consideration when monitoring the effectiveness of magnesium sulfate in the context of preeclampsia.

D. Negative clonus:

• Negative clonus is the correct therapeutic effect to monitor. Clonus refers to a series of involuntary, rhythmic, and repetitive muscle contractions and relaxations. In the context of magnesium sulfate administration for preeclampsia, negative clonus (the absence of abnormal reflexes) is a sign that the magnesium levels are within the therapeutic range, helping to prevent seizures.

The nurse should first administer oxygen at 2 L/min via nasal cannula because the client has signs of hypoxemia (low oxygen saturation) and respiratory distress (increased respiratory rate) that may worsen the chest pain and myocardial ischemia. Oxygen therapy can help improve oxygen delivery to the heart muscle and reduce the workload of the heart.
The nurse should then administer sublingual nitroglycerin as prescribed because nitroglycerin is a vasodilator that can help relieve chest pain by dilating the coronary arteries and improving blood flow to the heart. Nitroglycerin can also lower blood pressure and reduce cardiac preload and afterload, which can decrease myocardial oxygen demand.
Other choices:

• Prepare the client for cardiac catheterization: This may be a later intervention if the chest pain persists or if the client has a confirmed myocardial infarction, but it is not the first priority for the nurse. Cardiac catheterization is an invasive procedure that involves inserting a catheter into a large artery and advancing it to the coronary arteries to visualize any blockages or stenosis. The procedure may also involve angioplasty or stent placement to restore blood flow to the affected area.

• Request a prescription for an increase in statin: This may be a long-term intervention to lower the client’s LDL cholesterol and prevent further plaque formation in the coronary arteries, but it is not an immediate intervention for chest pain. Statins are lipid-lowering drugs that can reduce the risk of cardiovascular events in clients with CAD, but they do not have a direct effect on chest pain or myocardial ischemia.

• Check a STAT cardiac troponin: This may be a diagnostic test to confirm or rule out a myocardial infarction, but it is not an intervention for chest pain. Cardiac troponin is a protein that is released into the bloodstream when there is damage to the heart muscle. Elevated levels of cardiac troponin indicate a myocardial infarction or other cardiac injury.

• Request a prescription for a beta-blocker: This may be an adjunctive therapy to reduce chest pain and prevent complications, but it is not the first-line intervention for chest pain. Beta-blockers are drugs that block the effects of adrenaline on the heart and blood vessels, which can lower heart rate, blood pressure, and myocardial oxygen demand. Beta-blockers can also prevent arrhythmias and reduce mortality in clients with CAD.