A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take?

Choice A reason: Urine output of 20 mL/hr is below the desired 30 mL/hr during magnesium sulfate therapy, indicating potential toxicity or renal issues, not a therapeutic effect. Absence of eclampsia is the goal. Monitoring for low output risks missing seizure prevention, critical for maternal safety in preeclampsia management.

Choice B reason: Fetal heart rate of 116/min is within normal (110-160/min) but not a direct therapeutic effect of magnesium sulfate, which prevents seizures. Absence of eclampsia is key. Assuming heart rate is the focus risks overlooking maternal neurological status, critical for ensuring seizure prevention in preeclampsia treatment.

Choice C reason: Blood pressure of 150/92 mm Hg, while elevated, is not the primary therapeutic effect of magnesium sulfate, which targets seizure prevention, not hypertension. Absence of eclampsia is priority. Focusing on blood pressure risks neglecting seizure monitoring, critical for maternal safety in preeclampsia management with magnesium.

Choice D reason: Absence of eclampsia (seizures) is the primary therapeutic effect of magnesium sulfate in preeclampsia, stabilizing neuronal excitability, preventing life-threatening convulsions. Monitoring this ensures maternal safety, critical for preventing neurological damage, supporting fetal well-being, and guiding therapy adjustments in high-risk obstetric care.

Choice A reason: Discussing communication methods addresses client behaviors but not the caregiver’s stress from constant care. A daycare program offers respite. Focusing on communication risks neglecting caregiver well-being, potentially worsening burnout, critical to avoid in supporting caregivers of Alzheimer’s clients with high care demands.

Choice B reason: Suggesting antipsychotics for the client addresses behavior but not caregiver stress, and is inappropriate without medical evaluation. Daycare provides relief. Assuming medication is the solution risks unnecessary drug use, potentially causing side effects, critical to avoid in supporting caregiver health and client safety.

Choice C reason: Allowing the client time alone is unsafe for Alzheimer’s patients due to wandering risks and does not relieve caregiver stress. Daycare is effective. Assuming alone time helps risks client safety and caregiver burden, critical to prevent in ensuring comprehensive care for Alzheimer’s clients and caregivers.

Choice D reason: Assisting with a daycare program provides respite, reducing caregiver stress and preventing burnout while ensuring client safety. This intervention supports caregiver well-being, critical for sustained care quality, promoting mental health, and enabling effective management of Alzheimer’s disease in home settings with high care demands.