A 20-year-old primipara is admitted and diagnosed with pregnancy induced hypertension. Magnesium sulfate is ordered. Which of the following nursing responsibilities should be done before administering the drug?

Explanation

•Serum magnesium levels should be maintained at 4 to 8 mEq/L to prevent pre-eclamptic seizures. If the blood serum level rises above this, respiratory depression, hyporeflexia, cardiac arrhythmias, and cardiac arrest can occur.

•Checking the respiratory rate establishes a baseline before administration of the drug.  If respirations fall below 12 per minute, the nurse would withhold the drug.

•Checking the blood pressure establishes a baseline before administration of the drug. 

•As plasma magnesium levels rise above 4mEq/l, deep tendon reflexes lessen, disappearing altogether at 10mEq/L. Performing this test prior to administering the medication will help identify a baseline so the nurse will recognize if levels become high.

•Because magnesium is excreted from the body almost entirely through the urine, urine output must be monitored.

•The nurse does not need to assess bowel function or perform a vaginal exam at this time.