Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply

A. Prepare to prevent respiratory or cardiac arrest: The client's decreased level of consciousness and respiratory rate of 10 breaths/minute indicate a potential risk for respiratory or cardiac arrest. Immediate measures to maintain airway patency and support ventilation may be necessary. B. Stop infusion of magnesium: The client's decreased level of consciousness and absent deep tendon reflexes (DTR) bilaterally are signs of magnesium toxicity. Stopping the infusion of magnesium sulfate is essential to prevent further complications. C. Increasing IV fluids is not a priority in management of magnesium toxicity. D. Obtain serum magnesium level: With signs of magnesium toxicity, obtaining a serum magnesium level is necessary to confirm the diagnosis and guide further management. E. Administer oxygen: The client's oxygen saturation of 93% on room air indicates hypoxemia. Administering oxygen via nasal cannula to maintain oxygen saturation greater than 96% helps prevent further respiratory compromise. F. Obtaining blood pressure is not a priority. G. Administer calcium gluconate: Calcium gluconate is the antidote for magnesium toxicity. Since the client is showing signs of magnesium toxicity (decreased level of consciousness and absent DTRs), administering calcium gluconate is necessary to counteract the effects of magnesium H. Caesarian delivery is not part of management for magnesium toicity.