Nursing Clinical Practice Guide
Clinical Scenario: You are the nurse on the labor and delivery unit. Your patient, Anna, 36 weeks pregnant, calls you to her room stating she has a "crushing" headache and sees spots. Your assessment reveals BP 168/110, 3+ proteinuria, and 3+ patellar reflexes with sustained ankle clonus.
Nursing Intervention Strategy:- 1Immediate Assessment & SafetyPlace patient in a quiet, dimly lit room. Perform a focused neuro assessment: check DTRs, clonus, level of consciousness (LOC). Institute seizure precautions (pad side rails, have suction and O₂ ready).
- 2Communication & OrdersNotify the provider STAT. Anticipate orders for STAT labs (CBC, liver enzymes, creatinine) and a 24-hour urine collection for total protein.
- 3Medication AdministrationPrepare to administer Magnesium sulfate via IV pump as ordered (typically a loading dose of 4-6 g over 20-30 minutes, followed by a maintenance infusion of 1-2 g/hour). Monitor closely for toxicity.
- 4Ongoing MonitoringContinuous fetal monitoring. Strict intake and output (I&O) – urine output must be ≥30 mL/hr. Monitor for signs of pulmonary edema (crackles, dyspnea).
Patient Safety and Precautions:
* Key Point! MgSO₄ Toxicity: Assess DTRs hourly. Absent DTRs are the first sign of toxicity. Monitor respiratory rate (>12/min) and oxygen saturation. Have calcium gluconate at the bedside as the antidote.
* Do not leave the patient unattended. During a seizure, do not restrain; turn patient to left lateral position to prevent aspiration and improve placental blood flow.
* Avoid stimulants (e.g., loud noises, bright lights) which can trigger seizures.
Nursing Procedure & Medication Flow
Administering MgSO₄:
1. Verify order and patient identity.
2. Use an IV pump for precise control.
3. Administer loading dose as prescribed (e.g., 4 g in 100 mL NS over 20 min).
4. Initiate maintenance infusion (e.g., 1 g/hr in 100 mL NS).5. Monitoring Protocol:
* Vital signs, DTRs, clonus: Every 1 hour.
* Respiratory rate and effort: Every 1 hour.
* Urine output: Every hour (must be ≥30 mL/hr).
* Serum magnesium levels (therapeutic range: 4-7 mg/dL).
A Word from Your Senior Nurse
"Preeclampsia is one of the most critical conditions you'll manage in obstetrics. Trust your assessment – if a pregnant patient tells you she has a 'bad headache,' take it deadly seriously. That headache, plus brisk reflexes, is your patient's brain screaming for help. Your quick recognition of hyperreflexia and clonus, followed by prompt action, is what stands between a controlled situation and a life-threatening eclamptic seizure. Never just 'chart and wait.' Be the nurse who acts on those subtle (and not-so-subtle) warning signs. This vigilance saves two lives."