02/21/2023
A 29-year-old multigravida at 37 weeks’
gestation is being treated for severe preeclampsia
and has magnesium sulfate infusing at 3 g/hour. The
nurse has determined the priority nursing diagnosis
to be: risk for central nervous system injury related
to hypertension, edema of cerebrum. To maintain
safety for this client, the nurse should:
■ 1. Maintain continuous fetal monitoring.
■ 2. Encourage family members to remain at
bedside.
■ 3. Assess refl exes, clonus, visual disturbances,
and headache.
■ 4. Monitor maternal liver studies every 4 hours