A client with preeclampsia has been receiving an infusion containing magnesium sulfate. Blood pressure is \(160 / 80\), deep tendon reflexes are 1 plus, and urinary output for the past hour is \(100 \mathrm{~mL}\). The nurse should: A. Continue the infusion of magnesium sulfate while monitoring the client's blood pressure B. Stop the infusion of magnesium sulfate and contact the physician C. Slow the infusion rate and turn the client on her left side D. Administer calcium gluconate and continue to monitor the blood pressure

Short Answer

Expert verified
Answer: The most appropriate nursing action in this scenario is to slow the infusion rate and turn the client on her left side.

Step by step solution

01

Analyze the given data

The patient has preeclampsia and is on magnesium sulfate infusion. Their blood pressure is \(160/80\), deep tendon reflexes are 1 plus, and urinary output is \(100 \mathrm{~mL}\).
02

Evaluate Option A

In this option, we consider continuing the magnesium sulfate infusion while monitoring the blood pressure. Magnesium sulfate is a medication used to prevent seizures in women with preeclampsia. The current blood pressure (\(160/80\)) is high, so it's important to continue monitoring it. However, we need to evaluate other options as well to ensure we're taking the best course of action.
03

Evaluate Option B

Option B suggests stopping the magnesium sulfate infusion and contacting the physician. Deep tendon reflexes of 1 plus may suggest a beginning magnesium toxicity (normal is 2 plus). However, stopping the treatment could increase the risk of seizures. This option seems a bit extreme, so let's evaluate the other options as well.
04

Evaluate Option C

Option C is to slow the infusion rate and turn the client on her left side. Slowing the infusion rate could help reduce the risk of magnesium toxicity, while turning the client on her left side can improve blood flow to the fetus. This action seems the most reasonable, but let's consider Option D as well.
05

Evaluate Option D

Option D suggests administering calcium gluconate and continuing to monitor blood pressure. Calcium gluconate is an antidote for magnesium toxicity, but administering it without a clear indication of magnesium toxicity is not advised.
06

Choose the best course of action

Based on the analysis of all the options, Option C (slow the infusion rate and turn the client on her left side) is the best course of action in this scenario. This approach would manage the risk of magnesium toxicity while maintaining the benefits of magnesium sulfate infusion and optimizing blood flow to the fetus. So, the correct answer is: C. Slow the infusion rate and turn the client on her left side.

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