A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia.

Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.

Deep tendon reflexes

Respiratory rate

Urine output

Fetal heart rate

Serum magnesium level

Answer and Explanation

Correct Answer : A,B,C,E

The correct answer is choice A, B, C and E. The nurse should monitor for magnesium toxicity by assessing the deep tendon reflexes, respiratory rate, urine output and serum magnesium level of the client who has severe preeclampsia and is receiving magnesium sulfate IV. Magnesium toxicity can cause life-threatening complications such as hypotension, areflexia (loss of DTRs), respiratory depression, respiratory arrest, oliguria, shortness of breath, chest pains, slurred speech and cardiac arrest. The nurse should also have calcium chloride ready as an antidote for magnesium toxicity.

Choice D is wrong because fetal heart rate is not a direct indicator of magnesium toxicity. However, the nurse should still monitor the fetal heart rate and uterine activity per the Electronic Fetal Monitoring (EFM) Guideline.

Normal ranges for the assessments are:

• Deep tendon reflexes: 1+ to 4+ (normal to hyperactive)

• Respiratory rate: 12 to 20 breaths per minute

• Urine output: at least 30 mL per hour

• Serum magnesium level: 4 to 7 mg/dL (therapeutic range for preeclampsia)

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Correct Answer is ["A","C","D","E"]

Explanation

The correct answer is choice A, C, D and E. Here is why:

• Choice A is correct becausedisseminated intravascular coagulation (DIC)is a blood clotting disorder that can develop as a complication of HELLP syndrome.DIC can result in excessive bleeding or blood clots in various organs.

• Choice B is wrong becauseacute kidney injuryis not a common complication of HELLP syndrome.However, preeclampsia can cause kidney damage and proteinuria (high levels of protein in the urine).

• Choice C is correct becausepulmonary edemais a condition where fluid accumulates in and around the lungs, impairing oxygen absorption.It can occur as a complication of HELLP syndrome due to high blood pressure and fluid overload.

• Choice D is correct becauseplacental abruptionis a condition where the placenta separates from the uterus before delivery.

It can cause severe bleeding and fetal distress.It can occur as a complication of HELLP syndrome due to high blood pressure and abnormal blood clotting.

• Choice E is correct becausefetal growth restrictionis a condition where the fetus does not grow as expected.It can occur as a complication of HELLP syndrome due to reduced blood flow and oxygen delivery to the placenta.

Normal ranges for liver enzymes are:

• Alanine aminotransferase (ALT): 7 to 55 units per liter (U/L)

• Aspartate aminotransferase (AST): 8 to 48 U/L

• Alkaline phosphatase (ALP): 45 to 115 U/L

Normal range for platelet count is:

• 150,000 to 450,000 platelets per microlitre.

A. Administer calcium gluconate as an antidote if toxicity occurs B. Monitor the client’s blood glucose level every 4 hours C. Discontinue the infusion if the client’s respiratory rate is below 16/min D. Increase the infusion rate if the client’s urine output is above 30 mL/hr

Correct Answer is A

Explanation

Administer calcium gluconate as an antidote if toxicity occurs.Magnesium sulfate is a mineral that reduces seizure risks in women with severe preeclampsia.However, it can also cause side effects and toxicity, such as respiratory depression, muscle weakness, and cardiac arrest.Calcium gluconate is an antidote that can reverse the effects of magnesium sulfate and restore normal neuromuscular function.

Choice B is wrong because magnesium sulfate does not affect blood glucose levels.

There is no need to monitor the client’s blood glucose level every 4 hours.

Choice C is wrong because the infusion should be discontinued if the client’s respiratory rate is below 12/min, not 16/min.

A low respiratory rate indicates respiratory depression, which is a sign of magnesium toxicity.

Choice D is wrong because the infusion rate should not be increased if the client’s urine output is above 30 mL/hr.Urine output should be at least 30 mL/hr while administering magnesium sulfate to prevent accumulation of the drug in the body.

Increasing the infusion rate can increase the risk of toxicity.

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A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia. Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a diagnosis of HELLP syndrome. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is caring for a client who is receiving magnesium sulfate for severe preeclampsia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia.

Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.