Question

The nurse provides care for a client at 7 months gestation diagnosed with preeclampsia. An IV of magnesium sulfate is initiated at 2 grams/hour. Which is the most important action for the nurse perform?

A) Darken the client's room.
B) Perform a vaginal exam.
C) Measure the deep tendon reflexes.
D) Assist the client to a comfortable position.

Answer 1

The nurse should prioritize measuring the deep tendon reflexes when caring for a client diagnosed with preeclampsia and receiving magnesium sulfate to monitor for signs of exacerbation or magnesium toxicity.

Step-by-step explanation:

The most important action for the nurse to perform for a client at 7 months gestation diagnosed with preeclampsia and on an IV of magnesium sulfate is to measure the deep tendon reflexes (C). This monitoring is crucial as hyperreflexia can be a sign of exacerbating preeclampsia, and diminished reflexes may indicate magnesium toxicity. Magnesium sulfate is used to prevent seizures in preeclampsia, which can be a life-threatening complication. Measuring deep tendon reflexes helps the healthcare team to assess the efficacy and safety of the magnesium sulfate therapy.