Loss of deep tendon reflexes, respiratory rate under 12, or urine output under 30 mL/hr indicates magnesium toxicity; stop the infusion and give calcium gluconate.
Before you read
Test yourself first: 3 questions
Question 1 of 3
A client with cirrhosis has caput medusae and internal hemorrhoids. The nurse understands that these findings are direct consequences of:
Answer: A. Caput medusae (dilated periumbilical veins) and hemorrhoids result from portal hypertension. When scarring obstructs blood flow through the cirrhotic liver, pressure rises in the portal system and blood is diverted through collateral vessels, engorging veins around the umbilicus, esophagus, and rectum. These are not caused by low ammonia, excess clotting factors, or pancreatic enzymes.
Question 2 of 3
A client is admitted with a thrombotic ischemic stroke. The provider orders permissive hypertension in the acute phase. The nurse understands the rationale is to:
Answer: A. In acute ischemic stroke not receiving thrombolytics, blood pressure is often allowed to remain elevated (permissive hypertension) to maintain cerebral perfusion to the ischemic penumbra; aggressive lowering can worsen ischemia. It is not done to prevent bleeding (that concern applies more to lowering pressure), to raise intracranial pressure, or to speed clot formation.
Question 3 of 3
A nurse measures a client's blood pressure during the acute phase of an ischemic stroke who did not receive tPA. The provider allows permissive hypertension. What is the rationale?
Answer: B. Permissive (mildly elevated) blood pressure helps maintain cerebral perfusion pressure to the ischemic penumbra. Aggressively lowering BP can extend the infarct, so moderate elevation is often tolerated.
Keep the streak going with more questions like these, each with a full rationale.
What is pregnancy-induced hypertension?
The underlying problem is vasospasm and poor placental perfusion. The only cure is delivery; the priority is preventing seizures and stroke.
Key points to remember
- Diagnosis requires BP at or above 140/90 on two occasions after 20 weeks; severe features include BP at or above 160/110.
- Preeclampsia adds proteinuria, or in its absence, signs like thrombocytopenia, elevated liver enzymes, renal insufficiency, pulmonary edema, or visual/cerebral symptoms.
- Severe-feature warning signs include headache, visual changes, epigastric or right upper quadrant pain, and hyperreflexia with clonus.
- HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a dangerous variant.
- Magnesium sulfate is the drug of choice to prevent and treat seizures, not to lower blood pressure.
Signs & symptoms
- HTN, proteinuria, edema
- Headache, blurred vision
- Epigastric pain, ↑ DTRs
Nursing priorities
- Monitor blood pressure, deep tendon reflexes, urine output, and for headache, visual changes, and epigastric pain.
- Administer magnesium sulfate as ordered and monitor closely for toxicity (loss of reflexes, respiratory depression, decreased urine).
- Keep calcium gluconate at the bedside as the antidote for magnesium toxicity.
- Maintain a quiet, low-stimulation environment with seizure precautions and side rails padded.
- Give antihypertensives such as labetalol or hydralazine for severe-range blood pressure.
Labs & values
Patient teaching
- Report headaches, vision changes, swelling of the face or hands, or upper belly pain right away.
- Rest on your left side to improve blood flow to the baby.
- Keep all prenatal appointments for blood pressure and urine checks; this condition can worsen quickly.
Red flags: report now
- Loss of deep tendon reflexes, respiratory rate under 12, or urine output under 30 mL/hr indicates magnesium toxicity; stop the infusion and give calcium gluconate.
- Seizure activity signals eclampsia, an obstetric emergency; protect the airway and call for help.
- Severe headache, blurred vision, or epigastric pain warns of impending seizure or hepatic involvement and must be reported immediately.
References
Clinical references for this topic
