Sixteen-year-old primigravid 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: JIPMER Nursing Officer-2017

Explanation

• Magnesium sulfate is a central nervous system depressant administered to prevent eclamptic seizures.
• A primary and life-threatening sign of magnesium sulfate toxicity is respiratory depression, which occurs when serum magnesium levels become excessively high.
• Standard nursing protocol requires monitoring the respiratory rate at least hourly to detect respiratory depression (a rate below 12 breaths/minute) early and prevent respiratory arrest.
• Among the given options, hourly respiratory rate assessment is the most appropriate and critical monitoring frequency for ensuring patient safety during magnesium sulfate infusion.

Why Other Options Were Wrong

• Option A: Monitoring urinary output every 8 hours is dangerously infrequent. Magnesium is cleared by the kidneys, and oliguria (urine output less than 30 mL/hr) is a sign of decreased renal function, which can lead to toxic accumulation of magnesium.
• Option B: Assessing deep tendon reflexes (DTRs) every 4 hours is too infrequent. The loss of DTRs is one of the earliest signs of magnesium toxicity.
• Option D: Monitoring blood pressure every 6 hours is grossly inadequate for a patient with severe pregnancy-induced hypertension. This condition requires much more frequent monitoring to manage blood pressure and prevent complications like stroke.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Nursing assessment and monitoring for a patient receiving magnesium sulfate therapy to guide bedside assessment, documentation, and the next nursing action.
• Magnesium sulfate is a high-alert medication due to its narrow therapeutic window and the risk of severe adverse effects. Nurses play a crucial role in preventing toxicity through vigilant monitoring.
• The standard of care includes hourly assessments of respiratory rate, urine output, and deep tendon reflexes. Any deviation from normal must be reported immediately.
• The antidote for magnesium sulfate toxicity, calcium gluconate, must always be readily available at the patient's bedside.

How to Approach the Question

• First, identify the core of the question: it asks for the correct nursing monitoring action for a patient on IV magnesium sulfate for severe PIH.
• Recognize that magnesium sulfate is a high-alert medication with a risk of toxicity. Recall the key signs of magnesium toxicity: respiratory depression, loss of deep tendon reflexes, and oliguria.
• Evaluate each option based on the required frequency of monitoring for this high-risk situation.
• Option A (Urine output q8h), B (DTRs q4h), and D (BP q6h) all present dangerously infrequent monitoring intervals for this clinical scenario.
• Option C (Respiratory rate q1h) represents the standard, safe, and critical monitoring frequency to detect the most life-threatening complication of magnesium toxicity, which is respiratory depression.
• Conclude that monitoring the respiratory rate every hour is the correct and most essential nursing action among the choices.

Concept Tested & Keywords

• Concept Tested: Nursing assessment and monitoring for a patient receiving magnesium sulfate therapy.
• Stem keywords: sixteen-year-old, primigravid, severe pregnancy-induced hypertension, intravenous magnesium sulfate
• Lead-in keywords: which one of the following information
• Clinical cues: The patient is receiving magnesium sulfate, a high-alert medication known for causing respiratory depression in toxic doses.

Question ID

QzfbT5sJcm0QMiU3vvYYFu

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 158-159

E6 Obstetrics Williams p. 31-51