Page 184 - Critical Maternity & Newborn Health Nursing

- Lung sounds (pulmonary edema…short of breath)

Calcium gluconate: antidote for magnesium sulfate toxicity…be sure to

have it handy

Left side-lying position (helps prevent placenta ischemia and increases

blood flow to baby), bed rest/limit stimulation, fetal heart rate monitoring

(report decrease in fetal activity)

Assess for seizure activity “eclampsia”: there is a risk during and after labor

(up to 48 hours)

- Follow hospital’s protocol: have seizures precautions in place

beforehand if there is a risk (suction, airway management supplies,

padded side rails etc.)

- checks reflexes and clonus per protocol:

- To check for ankle clonus: quickly dorsiflex the patient’s foot

(point toes upward) and see response…if positive (clonus) foot will

start to bounce back and forth (it attempts to plantarflex) >3 bounces

or more is positive

- Seizure interventions:

1.Eclampsia…early may see facial twitching, changes in neuro

status, followed by full body tonic-clonic seizure (contraction and

stiffening of body followed by jerking of muscles)

2.Stay with patient and get help, don’t restrain patient, get on left

side (helps prevent aspiration, opens airway, and helps with blood

flow to placenta), oxygen 8 to 10 L, monitor baby, timing and

characteristics of seizure, may need medication and delivery of

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