A nurse is planning to administer hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.
Which of the following actions should the nurse take before giving the medication? (Select all that apply.)
A.
Check the client’s blood pressure
B.
Check the client’s pulse oximetry
C.
Check the client’s reflexes
D.
Check the client’s urine specific gravity
E.
Check the client’s magnesium level
The correct answer and Explanation is :
Before administering hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously, the nurse should take the following actions:
A. Check the client’s blood pressure
C. Check the client’s reflexes
E. Check the client’s magnesium level
Explanation:
- Check the client’s blood pressure (A):
Hydralazine is an antihypertensive medication commonly used in the management of severe pre-eclampsia to lower blood pressure. Monitoring blood pressure before administration is essential to determine baseline values and assess the effectiveness of the drug. Since hydralazine causes vasodilation and lowers blood pressure, giving it without checking the blood pressure first could result in severe hypotension, which could harm both the mother and fetus. - Check the client’s reflexes (C):
Reflexes should be assessed due to the administration of magnesium sulfate, which is used in pre-eclampsia to prevent seizures (eclampsia). Magnesium sulfate can cause central nervous system depression, leading to diminished or absent deep tendon reflexes, which are signs of magnesium toxicity. Diminished reflexes can indicate that the magnesium level is too high, putting the client at risk for complications such as respiratory depression or cardiac arrest. Monitoring reflexes helps ensure the safe administration of both magnesium sulfate and hydralazine. - Check the client’s magnesium level (E):
Magnesium levels must be monitored closely, as magnesium sulfate has a narrow therapeutic range. Excessive magnesium levels (hypermagnesemia) can lead to toxicity, while insufficient levels may fail to prevent seizures. The nurse should confirm that the magnesium level is within the therapeutic range before administering other medications like hydralazine, as magnesium sulfate can interact with other drugs and affect the patient’s hemodynamic status.
Incorrect options:
- Check the client’s pulse oximetry (B): While pulse oximetry is useful in assessing oxygenation, it is not necessary specifically prior to giving hydralazine unless respiratory compromise is suspected.
- Check the client’s urine specific gravity (D): Urine specific gravity is not directly related to the administration of hydralazine, though it may be monitored for fluid status and renal function in general.