A client who is 4 weeks pregnant, is at the first prenatal visit and reports to the nurse the use of alcohol. Which of the following should the nurse educate the client about, to be a safe level of alcohol intake during pregnancy?

Explanation:

A. Report of headache

Severe preeclampsia is characterized by hypertension (high blood pressure) along with other signs and symptoms of preeclampsia, such as proteinuria (protein in the urine) and end-organ dysfunction. Headache is a common symptom associated with severe preeclampsia and is often described as persistent and severe.

B. Polyuria

Polyuria, or excessive urination, is not typically associated with severe preeclampsia. In fact, decreased urine output (oliguria) can be a concern in severe cases due to reduced kidney function and fluid retention.

C. Tachycardia

Tachycardia, or a rapid heart rate, is not a typical finding in severe preeclampsia. In fact, hypertension and vascular constriction associated with preeclampsia can lead to normal or even lower heart rates in some cases.

D. Absence of clonus

Clonus refers to rhythmic, involuntary muscle contractions and relaxations. In the context of preeclampsia, the presence of clonus (especially hyperreflexia and positive clonus) is a concerning sign associated with central nervous system irritability and potential seizures. Absence of clonus would not be an expected finding in severe preeclampsia, as neurological manifestations such as hyperreflexia and clonus can occur in more severe cases.

Explanation:

A. Drowsiness: Mild drowsiness is a common side effect of magnesium sulfate therapy and is not necessarily indicative of toxicity. However, severe drowsiness or lethargy can be a sign of magnesium toxicity and should be reported to the provider.

B. Facial flushing: Facial flushing is a common side effect of magnesium sulfate administration and is generally not a sign of toxicity. It is often accompanied by warmth and redness of the skin but is not considered a serious adverse reaction.

C. Nausea: Nausea is another common side effect of magnesium sulfate therapy and is usually mild and transient. It is not typically indicative of toxicity unless it is severe and persistent.

D. Respiratory depression: Respiratory depression is a critical sign of magnesium toxicity. Excessive levels of magnesium can affect neuromuscular function, leading to respiratory muscle weakness and depression. This can result in shallow or slowed breathing, decreased oxygenation, and potential respiratory failure. Respiratory depression is a serious complication that requires immediate intervention, and the nurse should report it to the provider promptly.