# Situation: The nurse works in the labor, operating, and postpartum units of a government hospital. A laboring client with eclampsia at 7 cm dilation has been receiving magnesium sulfate at 2 g/hour for 10 hours. The nurse finds absent patellar reflexes, a respiratory rate of 10/min, and a urine output of 20 mL/hour for the past 2 hours. What should the nurse do FIRST?

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: The nurse works in the labor, operating, and postpartum units of a government hospital.

A laboring client with eclampsia at 7 cm dilation has been receiving magnesium sulfate at 2 g/hour for 10 hours. The nurse finds absent patellar reflexes, a respiratory rate of 10/min, and a urine output of 20 mL/hour for the past 2 hours. What should the nurse do FIRST?

## 보기

1. Stop the magnesium sulfate infusion **✔ 정답**
2. Draw blood for a serum magnesium level
3. Notify the physician of the findings
4. Give calcium gluconate 1 g intravenously over 3 minutes

**정답: 1**

## 해설

Absent reflexes and a respiratory rate below 12/min indicate magnesium toxicity, made worse by low urine output because magnesium is excreted by the kidneys. The first action is to stop the infusion so no more drug enters. The nurse then calls the physician, supports breathing, gives calcium gluconate as ordered, and sends a serum level.

## 심화 해설

Clinical situation A client with eclampsia has been receiving magnesium sulfate at 2 g/hour for 10 hours. The nurse identifies three findings that together signal magnesium toxicity: absent patellar reflexes, a respiratory rate of 10/min, and urine output of only 20 mL/hour over the past 2 hours.

Why the first action is to stop the infusion

Magnesium sulfate is a central nervous system depressant and neuromuscular blocker. Its therapeutic effect in eclampsia comes from suppressing neuronal excitability and preventing seizures, but the margin between the therapeutic range and toxicity is narrow. When deep tendon reflexes disappear and respirations slow below 12 breaths per minute, the client is already in the toxic range, and the highest priority is to prevent further drug from entering the circulation. Stopping the infusion immediately interrupts the source of ongoing toxicity. Every additional minute of infusion delivers more magnesium, which can progress to respiratory arrest and cardiac conduction abnormalities.

The low urine output makes this situation more urgent. Magnesium is excreted almost entirely by the kidneys, so when urine output falls below 30 mL/hour, the drug accumulates rather than clears. A client receiving 2 g/hour with only 20 mL/hour of urine output is retaining magnesium at a rate that will rapidly worsen toxicity. The kidney is the primary route of magnesium elimination, and oliguria converts a standard infusion rate into an overdose scenario.

Sequence of nursing actions in magnesium toxicity

| Priority order | Action | Rationale |
| --- | --- | --- |
| 1 | Stop the magnesium sulfate infusion | Halts further drug entry; this is the only action that immediately reduces the source of toxicity |
| 2 | Notify the physician | Reports the clinical findings and obtains orders for antidote and further management |
| 3 | Support respirations and monitor vital signs | Respiratory depression is the most immediate life threat; prepare for possible ventilatory support |
| 4 | Administer calcium gluconate as ordered | Calcium directly antagonizes magnesium at the neuromuscular junction and myocardium |
| 5 | Draw blood for serum magnesium level | Confirms the diagnosis and guides ongoing therapy, but does not treat the immediate danger |

Watch out! Calcium gluconate is the antidote for magnesium toxicity, but it is not the first action. The nurse must stop the infusion before giving the antidote; otherwise, more magnesium continues to enter while the antidote is being administered. Calcium gluconate also requires a physician's order and is given slowly intravenously.

Key point! The three classic signs of magnesium toxicity are absent or diminished deep tendon reflexes, respiratory depression (rate below 12/min), and oliguria (urine output below 30 mL/hour). These are the parameters the nurse must assess before each dose or at regular intervals during a continuous infusion.

Why the other options are not first

Drawing blood for a serum magnesium level provides useful confirmation, but it takes time and does nothing to stop the ongoing infusion. The client is already showing clinical signs of toxicity, so waiting for a laboratory value delays the critical intervention. Notifying the physician is essential but is the second step, not the first; the nurse can and should stop the infusion independently because it is a nursing action that immediately protects the client. Giving calcium gluconate without first stopping the infusion would be incomplete treatment and is not within the nurse's independent scope without an order.

Pathophysiology link

Magnesium competes with calcium at the presynaptic nerve terminal, reducing acetylcholine release and thereby depressing neuromuscular transmission. This explains why the patellar reflex disappears early: the reflex arc requires acetylcholine-mediated transmission at the neuromuscular junction, and magnesium blocks that step. Respiratory depression follows because the diaphragm and intercostal muscles depend on the same neuromuscular transmission. The progression of magnesium toxicity follows a predictable order: loss of deep tendon reflexes occurs first, followed by respiratory depression, and finally cardiac arrest if untreated. This predictable sequence is why reflex assessment is the single most important bedside monitoring parameter during magnesium sulfate therapy.

The therapeutic window for magnesium sulfate in eclampsia is narrow. Serum levels between 4 and 7 mEq/L are generally considered therapeutic for seizure prophylaxis. Loss of reflexes typically appears around 8 to 10 mEq/L, respiratory depression around 10 to 15 mEq/L, and cardiac conduction disturbances above 15 mEq/L. However, the nurse should not wait for serum levels to act; clinical signs are the trigger for immediate intervention.

## 임상 시나리오

Magnesium Sulfate Toxicity ResponseImmediate Nursing Priority in Eclampsia
When a client on magnesium sulfate develops absent patellar reflexes and a respiratory rate below 12/min, the first action is to stop the infusion immediately to halt further drug delivery.

Oliguria with urine output 20 mL/hour worsens toxicity because magnesium is excreted by the kidneys, leading to rapid drug accumulation.

CautionAfter stopping the infusion, notify the physician, support respirations, and prepare to administer calcium gluconate as ordered. Never give the antidote before stopping the magnesium source.

## 핵심 개념

- **magnesium sulfate toxicity** — A dangerous condition caused by excessive magnesium levels, characterized by loss of deep tendon reflexes, respiratory depression, and oliguria.
- **eclampsia** — A severe pregnancy complication marked by seizures or coma in a woman with preeclampsia, often managed with magnesium sulfate.
- **patellar reflex** — A deep tendon reflex tested by tapping the patellar tendon; its absence is an early sign of magnesium toxicity.
- **oliguria** — Urine output less than 30 mL/hour, which impairs magnesium excretion and increases toxicity risk.
- **calcium gluconate** — The antidote for magnesium sulfate toxicity, administered intravenously as ordered after stopping the magnesium infusion.

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