Of the following, what should the nurse assess before administering magnesium sulfate to a 20-year-old primipara with pregnancy-induced hypertension?
• 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 4 mEq/l, deep tendon reflexes lessen, disappearing altogether at 10 mEq/L. Performing this test prior to administering the medication will help
• 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.