A client with eclampsia has a seizure during labor.

Which of the following actions should the nurse take first?

Turn the client to the side.This is because turning the client to the side will prevent aspiration and maintain a patent airway, which is the priority intervention for a client who has a seizure.

Some possible explanations for the other choices are:

• Choice B. Administer oxygen via face mask.

This is not the first action because oxygen administration alone will not prevent aspiration or ensure a patent airway.Oxygen may be given after turning the client to the side and assessing the respiratory status.

• Choice C. Give additional magnesium sulfate.

This is not the first action because magnesium sulfate is used to prevent seizures in clients with eclampsia, not to treat them once they occur.Magnesium sulfate may be given after stabilizing the client and checking the serum magnesium level, which should be between 4 to 7 mg/dL (3.3 to 5.8 mEq/L) for therapeutic effect.

• Choice D. Document the duration and characteristics of the seizure.

This is not the first action because documentation is important but not urgent in this situation.The nurse should document the seizure after providing immediate care and notifying the provider.

Deep tendon reflexes are important to monitor because they indicate the level of neuromuscular irritability caused by magnesium sulfate therapy.Magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia.A healthcare provider will give the medication intravenously.If the deep tendon reflexes are absent or diminished, it may indicate magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.

Other statement options:

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A. Blood pressure: Blood pressure is a major sign of preeclampsia, but it is not the most important assessment to monitor when receiving magnesium sulfate therapy.Blood pressure may be controlled by other antihypertensive medications.

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C. Fetal heart rate: Fetal heart rate is important to monitor for fetal well-being, but it is not directly affected by magnesium sulfate therapy.Fetal heart rate may be monitored by nonstress test or biophysical profile.

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D. Urine output: Urine output is important to monitor for kidney function, but it is not the most important assessment to monitor when receiving magnesium sulfate therapy.Urine output may be measured by urine analysis or 24-hour urine sample.

Normal ranges:

• Blood pressure: less than 140/90 mm Hg

• Deep tendon reflexes: 2+ (normal) or 3+ (brisk) on a scale of 0 to 4

• Fetal heart rate: 110 to 160 beats per minute

• Urine output: at least 30 mL per hour