A sixteen-year-old primigravida patient admitted with severe pregnancy-induced hypertension is given intravenous magnesium sulfate. The nurse should obtain which one of the following information?

1. A

   Urinary output every 8 hours

2. B

   Deep tendon reflexes every 4 hours

3. C

   Respiratory rate every hour

4. D

   Blood pressure every 6 hours

Appeared in: NCL (MP) Nursing Officer - 2019

Explanation

• Magnesium sulfate is a central nervous system depressant, and its most severe toxic effect is respiratory depression.
• Respiratory arrest is the most life-threatening complication of magnesium sulfate overdose.
• Therefore, frequent assessment of the respiratory rate (at least hourly) is the highest priority nursing intervention to ensure patient safety.
• A respiratory rate below 12 breaths per minute is a critical sign of toxicity that requires immediate intervention, including stopping the infusion and notifying the provider.

Why Other Options Were Wrong

• Option A: Monitoring urinary output every 8 hours is dangerously infrequent. Magnesium is excreted by the kidneys, and a low urine output (oliguria) can cause the drug to accumulate to toxic levels.
• Option B: Checking deep tendon reflexes (DTRs) every 4 hours is too infrequent. The absence of DTRs is an early sign of magnesium toxicity, and assessment should be done every 1 to 2 hours.
• Option D: Monitoring blood pressure every 6 hours is grossly inadequate for a patient with severe pregnancy-induced hypertension. This condition requires very frequent BP checks to manage severe hypertension and prevent complications like stroke.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Nursing assessment and management of a patient receiving intravenous magnesium sulfate for severe pre-eclampsia to guide bedside assessment, documentation, and the next nursing action.
• Magnesium sulfate is a high-alert medication. Nurses must be vigilant in monitoring for signs of toxicity to prevent catastrophic outcomes like respiratory or cardiac arrest.
• The standard protocol for MgSO4 administration involves a loading dose followed by a continuous maintenance infusion, requiring continuous and meticulous nursing assessment.
• The antidote, calcium gluconate, must be immediately accessible at the patient's bedside whenever magnesium sulfate is being infused.

How to Approach the Question

• First, identify the key elements of the clinical scenario: a young, first-time pregnant patient with a severe condition (severe PIH) receiving a high-risk medication (IV magnesium sulfate).
• Recall the primary purpose and major risks of magnesium sulfate. Its purpose is to prevent seizures, but its major risk is CNS depression, leading to toxicity.
• Think about the signs of magnesium sulfate toxicity: respiratory depression, loss of reflexes, and decreased urine output.
• Evaluate each option based on the required frequency of monitoring to ensure patient safety. The most life-threatening complication should be monitored most frequently.
• Compare the frequencies given in the options to the standard of care. Respiratory depression is the most acute danger, so hourly checks are essential. The other options (q8h, q4h, q6h) are far too infrequent for this high-acuity situation.
• Select the option that reflects the highest priority and safest monitoring interval for the most critical potential complication.

Concept Tested & Keywords

• Concept Tested: Nursing assessment and management of a patient receiving intravenous magnesium sulfate for severe pre-eclampsia.
• Stem keywords: primigravida, severe pregnancy-induced hypertension, intravenous magnesium sulfate, nurse, information
• Lead-in keywords: which one of the following
• Clinical cues: Patient is a 16-year-old primigravida, indicating a first pregnancy which can have higher risks for pre-eclampsia.
• Clinical cues: The diagnosis is severe pregnancy-induced hypertension, a high-risk condition requiring intensive monitoring.

Question ID

Qjl7yT2hEY1Ji1oY9azo6u

Copy ID

Reference Book

E6 Obstetrics Williams p. 31-51