Question

A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?

A. Monitor for signs of magnesium toxicity
B. Encourage increased oral fluid intake
C. Administer diuretics concurrently
D. Administer magnesium sulfate bolus

Answer 1

The nurse should monitor for signs of magnesium toxicity when a client with preeclampsia is receiving magnesium sulfate via IV infusion. Continuous monitoring of reflexes, respiratory rate, and serum magnesium levels is crucial for patient safety.

Step-by-step explanation:

A nurse developing a plan of care for a client with preeclampsia who is receiving magnesium sulfate via IV infusion should prioritize monitoring for signs of magnesium toxicity. Magnesium sulfate is administered to prevent seizures in clients with preeclampsia; however, excessive levels can lead to toxicity. Signs of magnesium toxicity include decreased respiratory rate, lethargy, muscle weakness, and decreased reflexes. Ensuring the client does not develop magnesium toxicity is critical, as severe cases can be fatal. Increased oral fluid intake is usually not encouraged due to the risk of fluid overload and pulmonary edema in preeclampsia. Diuretics are not typically administered concurrently unless there is evidence of fluid overload and are prescribed cautiously. Administering a magnesium sulfate bolus is part of initial management but is not a continuous intervention. Continuous monitoring of reflexes, respiratory rate, and serum magnesium levels is vital in managing the infusion effectively and safely.