A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. The client has been receiving magnesium sulfate for tocolysis for the past 12 hours. Which nursing intervention is the priority at this time?
1Monitor deep tendon reflexes and respiratory rate every hour✓ 정답
2Encourage the client to ambulate to promote circulation
3Administer calcium gluconate as ordered for muscle cramps
4Increase fluid intake to prevent dehydration from the medication
해설
Monitoring deep tendon reflexes and respiratory rate hourly is the priority to detect early signs of magnesium sulfate toxicity, such as CNS depression and respiratory depression. Other interventions are important but secondary to preventing life-threatening complications.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing action for a patient receiving Magnesium sulfate for tocolysis (inhibition of preterm labor). Magnesium sulfate acts as a central nervous system (CNS) depressant and smooth muscle relaxant. While therapeutic levels effectively suppress uterine contractions, the Key Point! is that the therapeutic window is narrow, and toxicity can lead to life-threatening complications like respiratory depression and cardiac arrest. Therefore, vigilant monitoring for signs of toxicity is the highest nursing priority.
Answer Rationale: Key Point! The priority intervention is to Monitor deep tendon reflexes and respiratory rate every hour. This is a standard, critical safety protocol. Deep tendon reflexes (DTRs) are one of the first signs to diminish with rising magnesium levels. A respiratory rate below 12 breaths per minute is a red flag for impending respiratory depression. Hourly monitoring allows for early detection and intervention before the patient progresses to severe toxicity.
Distractor Analysis:
Watch out for confusion! Option ②, encouraging ambulation, is contraindicated for a patient in preterm labor on tocolytic therapy. Bed rest is typically prescribed to reduce uterine activity and pressure on the cervix.
Option ③, administering calcium gluconate, is the antidote for severe magnesium sulfate toxicity (e.g., respiratory arrest). It is not a routine intervention for muscle cramps in this context and would only be given for confirmed, life-threatening toxicity per specific orders.
Option ④, increasing fluid intake, is a general supportive measure. While magnesium sulfate can cause flushing and a feeling of warmth, aggressive fluid intake is not the priority over direct toxicity monitoring. Furthermore, fluid overload must be avoided.
Related Concepts: Nursing care for a patient on magnesium sulfate also includes monitoring urinary output (should be > 30 mL/hr), level of consciousness, and serum magnesium levels. The goal is to maintain a therapeutic level (typically 4-8 mg/dL) while preventing toxicity.
Concept Summary
Concept
Key Points
Magnesium Sulfate (Tocolysis)
Used to stop preterm labor. Therapeutic level: 4-8 mg/dL. Acts as a CNS & neuromuscular depressant.
Priority Monitoring (The "Big 3")
1. Deep Tendon Reflexes (DTRs) (absent = toxicity) 2. Respiratory Rate (< 12/min = toxicity) 3. Urinary Output (< 30 mL/hr = risk of toxicity due to decreased excretion).
Signs of Toxicity
Loss of DTRs, respiratory depression, somnolence, slurred speech, hypotension, cardiac arrest.
Antidote
Calcium gluconate (10% solution) - kept at bedside for emergency use.
Anatomy, Physiology & Pharmacology Points
Magnesium sulfate works by competing with calcium at the neuromuscular junction, inhibiting the release of acetylcholine and decreasing neuronal excitability. This relaxes smooth muscle (uterus, blood vessels) and depresses the CNS. It is excreted almost entirely by the kidneys, making renal function and urine output critical factors in preventing toxicity.
Memory TipsMnemonic for Toxicity Signs: "REDS" Respiratory Depression
Extreme weakness / Electrolyte imbalance (hypermagnesemia)
Decreased/absent DTRs
Somnolence / Sedation
Remember: Monitor the patient to avoid seeing "REDS"!
High-Frequency NCLEX Topics
Magnesium sulfate administration (for preeclampsia/eclampsia and tocolysis) is a classic NCLEX-RN topic. Expect questions on: priority assessments, signs of toxicity, the antidote, and patient safety precautions. Always prioritize airway, breathing, and circulation (ABCs)—monitoring respiratory rate is directly assessing the "B."
Watch Out for Question Variations!
* Instead of asking for the priority intervention, the question might ask: "Which finding requires immediate notification of the provider?" (Answer: Respiratory rate of 10/min).
* The scenario could shift to magnesium sulfate for preeclampsia. The priority monitoring (DTRs, RR, UOP) remains identical.
* A question might ask for the rationale behind an intervention: "The nurse monitors deep tendon reflexes hourly to assess for which complication?" (Answer: Magnesium sulfate toxicity).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on the labor and delivery unit. Your patient, Maria, is 32 weeks pregnant and receiving a continuous IV infusion of magnesium sulfate at 2 g/hr for preterm labor. She has been on the infusion for 12 hours.
Nursing Intervention Strategy:
1AssessmentUpon starting your shift, perform a comprehensive baseline assessment. Check her DTRs (patellar and biceps), count her respiratory rate for a full minute, assess her level of consciousness, and review her intake/output record for the last 4 hours.
2Planning & ImplementationSet a timer to reassess DTRs and respiratory rate every hour. Document meticulously. Ensure the calcium gluconate antidote is available at the bedside. Maintain strict bed rest with side-lying positioning to optimize uteroplacental perfusion.
3Patient EducationExplain to Maria and her family why you are checking her reflexes and breathing so frequently. "We're checking these to make sure the medication level is just right—enough to help your uterus relax, but not so much that it causes side effects." Instruct her to report immediately any feelings of extreme weakness, difficulty breathing, or blurred vision.
4EvaluationContinuously evaluate for therapeutic effect (decrease in contraction frequency/intensity) and absence of adverse effects. If DTRs become hypoactive or RR drops, you must act.
Patient Safety and Precautions:
* Contraindication/Caution: Magnesium sulfate is contraindicated in patients with myasthenia gravis (exacerbates weakness) and must be used with extreme caution in patients with renal impairment.
* Medication Administration: Always use an IV infusion pump. Double-check the concentration and rate with another nurse. Never bolus the medication.
* Key Monitoring Points: The "hourly vitals" for mag sulfate are DTRs and RR. Also monitor for flushing, warmth, nausea, and headache (common side effects).
Nursing Procedure & Medication FlowProcedure for Hourly Magnesium Sulfate Assessment:
1. Wash hands, introduce yourself, provide privacy.
2Assess Respiratory RateCount for 60 seconds while the patient is at rest. Observe for depth and effort.
3Assess Deep Tendon Reflexes* Patellar Reflex: Have patient sit with legs dangling or lie supine. Tap the patellar tendon just below the kneecap.
* Biceps Reflex: Support the patient's arm, tap the biceps tendon.
* Grade: 0 (absent), +1 (hypoactive), +2 (normal), +3 (hyperactive), +4 (hyperactive with clonus).
4Assess Level of ConsciousnessUse simple questions. "Maria, can you tell me your name and where you are?"
5Check Urinary OutputEnsure Foley catheter is draining properly if present, or track voided amounts. Output should be > 30 mL/hr.
6Document & ActDocument all findings. Report any abnormal findings (absent DTRs, RR < 12, decreased LOC) to the provider immediately.
A Word from Your Senior Nurse
"Managing a patient on magnesium sulfate is a perfect example of how nursing vigilance saves lives. You are the one at the bedside every hour, catching the subtle change from +1 to absent reflexes or a respiratory rate slowing from 14 to 11. That early catch is what prevents a code blue. On the NCLEX, they test this because it's a non-negotiable safety standard in real practice. Don't just memorize 'check DTRs'—understand that you're checking because magnesium depresses the nervous system, and lost reflexes are the canary in the coal mine. Think like a nurse, protect your patient, and you'll ace these questions."
Magnesium Sulfate — A medication used as a tocolytic to inhibit uterine contractions in preterm labor and as an anticonvulsant in preeclampsia/eclampsia. It is a CNS depressant and smooth muscle relaxant with a narrow therapeutic window.
Tocolytic Therapy — Medical treatment aimed at suppressing premature labor (preterm labor) to delay delivery, allowing time for administration of corticosteroids to promote fetal lung maturity.
Deep Tendon Reflexes — Reflexes elicited by tapping a tendon, such as the patellar reflex. Assessment of DTRs is a key nursing action to monitor for magnesium sulfate toxicity, as they are one of the first neurological functions to diminish.
Calcium Gluconate — The antidote for severe magnesium sulfate toxicity. It works by antagonizing the neuromuscular and cardiac depressant effects of magnesium. A 10% solution is typically kept at the bedside for emergency use.
Preterm Labor — Regular uterine contractions with cervical change occurring after 20 weeks and before 37 weeks of gestation. Management focuses on stopping labor if possible and promoting fetal lung maturity.