A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's urine output for the past hour is 25 mL and deep-tendon reflexes are absent. Which of the following actions should the nurse take? (Select all that apply)
Explanation & Rationale
A. The client shows signs of magnesium sulfate toxicity: oliguria (urine output <30 mL/hr) and absent deep-tendon reflexes. These are potentially life-threatening signs that require immediate intervention, including preparing for emergent delivery if maternal or fetal status is unstable. Stopping the magnesium infusion and preparing for emergency interventions is critical. B. Administering Vitamin K is not indicated in this scenario. Vitamin K is used to treat or prevent coagulopathy, such as in newborns or clients on certain anticoagulants, but it does not counteract magnesium toxicity. C. Increasing the magnesium sulfate infusion would worsen toxicity. The correct action is to stop the infusion immediately and prepare to administer calcium gluconate as an antidote if prescribed. D. Assessing maternal glucose levels is unrelated to the immediate concern of magnesium toxicity. While glucose monitoring may be part of overall prenatal care, it is not a priority in this emergent situation. E. Placing the client in Trendelenburg position is not indicated. Positioning does not treat magnesium toxicity and could worsen respiratory compromise in a client with severe preeclampsia. The priority is stopping magnesium, assessing maternal and fetal status, and preparing for emergency delivery if necessary.