A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? Select all that apply.

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Seizures are a potential complication of worsening preeclampsia, also known as eclampsia. Seizure precautions should be in place for all clients with preeclampsia. Side rails should be padded and the bed kept in the lowest position to prevent trauma during a seizure. Functioning suction equipment and supplemental oxygen should be available at the bedside (Option D). During a seizure, the nurse should turn the client to the left side to prevent aspiration and promote uteroplacental blood flow. After the seizure subsides, the nurse should suction any oral secretions and apply oxygen 8-10 L/min by facemask. Magnesium sulfate is a central nervous system (CNS) depressant commonly prescribed to prevent seizures in clients with preeclampsia. Deep tendon reflexes should be assessed hourly during administration (Option A). Hyperreflexia or clonus may indicate impending seizure activity, whereas hyporeflexia may indicate magnesium toxicity. Calcium gluconate is the reversal agent administered in the event of magnesium toxicity and should be immediately available (Option B). Environmental stimuli should be minimized to decrease risk for seizures. This may include limiting visitors and the number of caregivers entering/exiting the client's room (Option E). (Option C) Severe preeclampsia is associated with CNS irritability, and excessive stimulation should be avoided. Lights should be lowered to decrease visual stimuli and risk for seizures. Educational objective: Magnesium sulfate is commonly prescribed to clients with severe preeclampsia to prevent seizures and is a central nervous system depressant. Safety measures for preeclampsia include seizure precautions and decreasing environmental stimuli.

A Client Is Admitted to the Labor and Delivery Unit