Chapter 28
284. The nurse is monitoring a client who is receiving oxytocin to induce labor. Which
assessment findings should cause the nurse to immediately discontinue the oxytocin
infusion? Select all that apply.
1. Fatigue
2. Drowsiness
3. Uterine hyperstimulation
4. Late decelerations of the fetal heart rate
5. Early decelerations of the fetal heart rate
285. A pregnant client is receiving magnesium sulfate for the management of preeclampsia.
The nurse determines that the client is experiencing toxicity from the medication if which
findings are noted on assessment? Select all that apply.
1. Proteinuria of 3 +
2. Respirations of 10 breaths per minute
3. Presence of deep tendon reflexes
4. Urine output of 20 mL in an hour
5. Serum magnesium level of 4 mEq/L (2 mmol/L)
286. The nurse asks a nursing student to describe the procedure for administering
erythromycin ointment to the eyes of a newborn. Which student statement indicates that
further teaching is needed about administration of the eye medication?
1. “I will flush the eyes after instilling the ointment.”
2. “I will clean the newborn’s eyes before instilling ointment.”
3. “I need to administer the eye ointment within 1 hour after
delivery.”
4. “I will instill the eye ointment into each of the newborn’s conjunctival sacs.”
287. A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on
magnesium sulfate and contractions have stopped. If the client’s labor can be inhibited for
the next 48 hours, the nurse anticipates a prescription for which medication?
1. Nalbuphine
2. Betamethasone
3. Rho(D) immune globulin
4. Dinoprostone vaginal insert
288. Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before
administration of methylergonovine, what is the priority assessment?
1. Uterine tone
2. Blood pressure
3. Amount of lochia
4. Deep tendon reflexes
Purpose of the tool: This tool describes the key perinatal safety elements with examples for the safe administration of magnesium sulfate during labor. The key elements are presented within the framework of the Comprehensive Unit-based Safety
Program (CUSP). Who should use this tool: Nurses, physicians, midwives, pharmacists, and other labor and delivery (L&D) unit staff responsible for the preparation and administration of magnesium sulfate during labor. How to use this tool: Review the key perinatal safety elements with L&D leadership and unit staff to determine how the elements will be implemented on your L&D unit. Consider any existing facility policies or processes
related to magnesium sulfate use. Consider using preprinted orders, standing orders, and staff training to support implementation. A sample of how some of these key perinatal safety elements can be incorporated into a unit approach to safe magnesium sulfate administration is provided in the Appendix of this tool.AHRQ Safety Program for Perinatal Care
Key Perinatal Safety Elements
Standard criteria established for magnesium sulfate use. |
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Use uniform and standard drug packaging, preparation, and labeling.12 |
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Standardize magnesium sulfate dosing using a calibrated infusion pump with free-flow protection. |
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Use uniform parameters for maternal and fetal monitoring and provider notification prior to initiation of magnesium sulfate and during infusion. | The use of uniform parameters for fetal and maternal monitoring and provider notification before and during magnesium sulfate use minimizes variability across providers and nursing staff in order to reduce the risk of error. | ||||||||||||||||||
Standardize laboratory reporting of serum magnesium levels. | Hospital policy and process for uniform reporting of serum magnesium levels. Magnesium levels can be reported as milligrams per deciliter (mg/dL), milliequivalents per liter (mEq/L) and millimoles per liter (mmmol/L), and the same magnesium level would be reported using different numbers depending on the unit of measure. Bedside staff, providers, and lab personnel should agree on one unit for reporting and communicating magnesium levels to avoid miscommunication and delays in timely care.10 | ||||||||||||||||||
Create Independent Checks (CUSP Science of Safety) | |||||||||||||||||||
Assess appropriateness of magnesium use in patient by staff other than the ordering provider. | An independent verification of indications and maternal and fetal status per unit-established standard criteria can minimize medication use in cases where risk may exceed benefit. These criteria may include—
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Use preprinted orders or electronic order entry for magnesium sulfate order. | Unit process for ordering magnesium using preprinted orders or electronic order entry reduces dosing errors due to incorrect dose or illegible orders. Avoidance of abbreviations for magnesium sulfate.10,12 | ||||||||||||||||||
Use independent verification whenever there is a rate change or a new magnesium sulfate bag is hung. | A second qualified staff member independently checks that the magnesium bag is clearly labeled, contains the correct dose, and that tubing and pump are set up correctly whenever a new bag is hung or a rate change is made.10 This verification is facilitated by tracing the tubing by hand from the IV bag to the pump, and then to the patient.14 | ||||||||||||||||||
Use uniform parameters for maternal and fetal monitoring at regular intervals. | Use uniform parameters for maternal and fetal monitoring at regular time intervals per unit-established processes during loading dose and maintenance infusion to identify changes in status. Various clinical references offer parameters for monitoring:3,10,15
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Use maternal and fetal parameters for provider notification. | Use of uniform, unit-established parameters for provider notification ensures that signs of potential adverse effects or clinical deterioration are communicated for situational awareness and response if needed.
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Have standing orders for nurses to respond to signs and symptoms of magnesium toxicity, with quick access to antidote. | Use of uniform, unit-established standing orders allows nurses to provide initial management in response to suspected magnesium toxicity. Magnesium toxicity is a clinical diagnosis, and serum levels do not always correlate with clinical signs and symptoms; thus, nurses who monitor patients receiving magnesium sulfate should—
Standing orders for nurse response for signs and symptoms of magnesium toxicity can include—
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Learn From Defects (CUSP Module) | |||||||||||||||||||
Debrief and analyze near misses and adverse events related to magnesium sulfate use. |
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Share outcomes or process improvements from the informal (debriefing) and formal analysis with staff to achieve transparency and organizational learning | Unit can decide its approach to reviewing cases where magnesium sulfate was used outside of the unit’s established criteria for use. This might include an existing medical peer-review process or review by a perinatal safety or quality committee. | ||||||||||||||||||
Have a process in place to review severe maternal or neonatal morbidity and mortality events. | Unit can decide its approach to reviewing cases of severe maternal or neonatal morbidity or mortality. This might include an existing medical peer-review process or review by a perinatal safety or quality committee. A sample process and forms for a committee review are available at the Council on Patient Safety in Women’s Health Care, www.safehealthcareforeverywoman.org. | ||||||||||||||||||
Use independent verification whenever there is a rate change or a new magnesium sulfate bag is hung. | Sites can decide how often this information will be shared, how much will be shared, and with whom, and whether this should be specified in a unit policy or handled more informally. | ||||||||||||||||||
Simulation (Safety Program for Perinatal Care Signature Element) | |||||||||||||||||||
Sample Scenarios:
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Teamwork Training (TeamSTEPPS®) | |||||||||||||||||||
Situational awareness during magnesium sulfate use. | Situational awareness refers to all staff caring for the patient—
In the context of magnesium sulfate use, this includes staff alertness for early signs of abnormal fetal or maternal status, and knowing the plan for a timely response to prevent further deterioration. | ||||||||||||||||||
Use SBAR (Situation, Background, Assessment, and Recommendation), callouts, huddles, and closed-loop communication techniques. | Use SBAR, callouts, huddles, and closed-loop communication among team members. In the context of magnesium sulfate use, these techniques are particularly useful—
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Communicate during transitions of care. | Use of transition communication techniques assures a shared mental model of plan of care and perceived risks between shifts, between units. This may include bedside review by nursing team of pump settings, mainline IV fluids, and written orders for magnesium sulfate.10 | ||||||||||||||||||
High-reliability teams:
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Patient and Family Engagement (CUSP) | |||||||||||||||||||
Discuss risks and benefits of intrapartum or postpartum magnesium sulfate use. | Use unit-established process for conveying risks and benefits of magnesium sulfate use to patient and family. | ||||||||||||||||||
Educate patient/family regarding magnesium sulfate use. |
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References
- Doyle LW, Crowther CA, Middleton P, et al. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database Syst Rev 2009 Jan 21;(1):CD004661. Review. PMID: 19160238.
- Duley L, Gülmezoglu AM, Henderson-Smart DJ, et al. Magnesium sulphate and other anticonvulsants for women with pre-eclampsia. Cochrane Database Syst Rev 2010 Nov 10;(11):CD000025. doi: 10.1002/14651858.CD000025.pub2. Review. PMID: 21069663.
- American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. Committee Opinion No. 652: Magnesium sulfate use in obstetrics. Obstet Gynecol 2016 Jan;127(1):e52-3. doi: 10.1097.AOG. 0000000000001267. PMID: 26695587.
- Committee on Obstetric Practice. Committee Opinion no. 514: emergent therapy for acute-onset, severe hypertension with preeclampsia or eclampsia. Obstet Gynecol 2011 Dec;118(6):1465-8. doi: 10.1097/AOG.0b013e31823ed1ef. PMID: 22105295.
- American College of Obstetricians and Gynecologists; Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 159: Management of preterm labor. Obstet Gynecol 2016 Jan;127(1):e29-e38. doi: 10.1097/AOG. 0000000000001265. PMID: 26695585.
- American College of Obstetricians and Gynecologists Committee on Obstetric Practice; Society for Maternal-Fetal Medicine. Committee Opinion No. 455: Magnesium sulfate before anticipated preterm birth for neuroprotection. Obstet Gynecol 2010 Mar, reaffirmed 2015;115(3):669-71. doi: 10.1097/AOG.0b013e3181d4ffa5. PMID: 20177305. 7
- WHO Recommendations for Prevention and Treatment of Pre-Eclampsia and Eclampsia. Geneva: World Health Organization; 2011. PMID: 23741776.
- Magnesium Sulfate FDA-approved Drug Label. May 29, 2013. //www.accessdata.fda.gov/drugsatfda_docs/label/2013/019316s018lbl.pdf. Accessed May 2, 2016. 9
- Magnesium Sulfate: Drug Safety Communication—Recommendation Against Prolonged Use in Pre-term Labor. //www.fda.gov/Drugs/DrugSafety/ucm353333.htm. Issued 5/30/2013.
- Simpson KR, Knox GE. Obstetrical accidents involving intravenous magnesium sulfate: recommendations to promote patient safety. MCN Am J Matern Child Nurs 2004 May-Jun;29(3):161-9; quiz 170-1. PMID: 15123972.
- Failure to Set a Volume Limit for a Magnesium Bolus Dose Leads to Harm. Acute Care ISMP Medication Safety Alert. June 3, 2010.
- Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000. PMID: 25077248.
- ISMP List of High-Alert Medications in Acute Care Settings. Institute for Safe Medication Practices (ISMP). //www.ismp.org/tools/institutionalhighAlert.asp Accessed May 2, 2016.
- Preventing Magnesium Toxicity in Obstetrics. Acute Care ISMP Medication Safety Alert. October 20, 2005.
- Simpson KR, Creehan PA. (eds). AWHONN’s Perinatal Nursing 4th ed. Lippincott; 2014.
Appendix
Every effort was made to ensure the accuracy and completeness of this resource. However, the U.S. Department of Health and Human Services makes no warranties regarding errors or omissions and assumes no responsibility or liability for loss or damage resulting from the use of information contained within.
SAMPLE Safe Medication Administration Process for Magnesium Sulfate
(References are located in the reference list above.)
1. Verifying and documenting indications for use | Verify and document indications and absence of contraindications for use of magnesium sulfate when receiving orders for magnesium sulfate.
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2. Assessment | Baseline maternal and fetal assessment and periodic assessment. Assessment documentation on labor and delivery flowsheet.
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3. Administration |
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4. Provider notification parameters and standing orders for responding to suspected magnesium toxicity |
Adapted from Simpson, 2004.10
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6. Patient comfort and education |
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7. Communication |
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Page last reviewed November 2018
Page originally created April 2017
Internet Citation: Safe Medication Administration: Magnesium Sulfate. Content last reviewed November 2018. Agency for Healthcare Research and Quality, Rockville, MD.
//www.ahrq.gov/hai/tools/perinatal-care/modules/strategies/medication/tool-safe-mgso4.html