Difficulty: Medium
Average Score: 81%
Simulated
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
Correct answer
B
Rationale
The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate can lead to magnesium toxicity, causing respiratory depression and cardiac arrest. Calcium gluconate is the antidote for magnesium toxicity, so having it readily available is crucial for immediate administration if toxicity occurs. Option A is incorrect as fluid intake should not be restricted in preeclampsia. Option C is incorrect as deep tendon reflexes should be assessed more frequently (every 1-2 hours) due to the risk of hypermagnesemia. Option D is incorrect as intake and output should be monitored hourly to detect any changes in renal function.