A nurse is preparing to administer magnesium sulfate IV to a client who has severe preeclampsia.

Which of the following actions should the nurse take? (Select all that apply.)

Choice A is correct because magnesium sulfate is excreted in the urine and a decreased urine output places the client at risk for magnesium toxicity. The nurse should monitor the client’s urine output hourly and report any decrease to the provider.

Choice B is wrong because hyperactive (3+ or 4+) deep tendon reflexes are a common physical finding of preeclampsia or eclampsia and do not require an action. The nurse should check the client’s deep tendon reflexes more frequently than every 4 hours to detect any signs of magnesium toxicity, such as absent or hypoactive reflexes.

Choice C is correct because calcium gluconate is the antidote for magnesium toxicity and should be readily available in case of respiratory depression, cardiac arrest, or other signs of overdose. The nurse should administer 10 mL of 10% calcium gluconate IV push over 3 to 5 minutes if needed.

Choice D is correct because magnesium sulfate should be administered via a piggyback infusion using an infusion pump to ensure accurate and safe delivery. The nurse should not administer magnesium sulfate as a bolus or through a primary IV line.

Choice E is wrong because the infusion rate of magnesium sulfate should not be titrated according to the client’s blood pressure, but according to the client’s serum magnesium level, which should range from 4 to 7 mEq/L. The nurse should notify the provider of any low or high serum magnesium level and adjust the infusion rate accordingly. The nurse should also administer antihypertensive medications other than magnesium for sustained hypertension.

Normal ranges:

• Urine output: at least 30 mL/hour

• Deep tendon reflexes: 1+ or 2+

• Respiratory rate: 12 to 20 breaths/minute

• Serum magnesium level: 4 to 7 mEq/L

• Blood pressure: less than 140/90 mm Hg