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)

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Headache that does not respond to analgesics.This is a possible sign of postpartum pre-eclampsia, a rare condition that occurs when a woman has high blood pressure and excess protein in her urine soon after childbirth.Postpartum pre-eclampsia can cause seizures and other serious complications if not treated.

Choice B is wrong because breast engorgement and tenderness are normal symptoms of breastfeeding and do not indicate postpartum pre-eclampsia.

Choice C is wrong because lochia rubra with small clots is a normal discharge of blood and tissue from the uterus after delivery and does not indicate postpartum pre-eclampsia.

Choice D is wrong because perineal pain and swelling are common after vaginal delivery and do not indicate postpartum pre-eclampsia.

Normal ranges for blood pressure are below 120/80 mm Hg and for protein in urine are below 150 mg/day.

A. “I should avoid foods that are high in sodium.” B. “I should lie on my left side for at least 2 hours a day.” C. “I should check my blood pressure at home every day.” D. “I should take a baby aspirin every day as prescribed.”

Correct Answer is D

Explanation

“I should take a baby aspirin every day as prescribed.” Taking a baby aspirin daily has been shown to reduce the risk of developing preeclampsia by about 15%.If you have risk factors for preeclampsia, your healthcare provider may recommend starting aspirin in early pregnancy (by 12 weeks gestation).

Choice A is wrong because avoiding foods that are high in sodium does not prevent preeclampsia.Sodium intake does not affect blood pressure in pregnancy.

Choice B is wrong because lying on your left side for at least 2 hours a day does not prevent preeclampsia.However, lying on your left side may help improve blood flow to your placenta and your baby.

Choice C is wrong because checking your blood pressure at home every day does not prevent preeclampsia.However, monitoring your blood pressure at home may help detect signs of preeclampsia early and alert you to seek medical attention if needed.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a client who had severe pre-eclampsia and delivered a healthy baby at 36 weeks of gestation. The nurse should instruct the client to report which symptom to the provider as a possible sign of postpartum pre-eclampsia?

Correct Answer is A

Explanation

A nurse is teaching a client who is at risk for developing preeclampsia. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is evaluating the fetal status of a client who has preeclampsia and is receiving magnesium sulfate. Which of the following findings should the nurse report to the provider as a sign of fetal compromise?

A nurse is reviewing the electronic health record of a client who has severe preeclampsia and is being induced with oxytocin. Which of the following findings should the nurse report to the provider immediately?

A nurse is caring for a client who has severe pre-eclampsia and is receiving hydralazine IV. Which of the following adverse effects should the nurse monitor for?

A nurse is providing discharge teaching to a client who had HELLP syndrome and a cesarean birth. The nurse should instruct the client to report which of the following findings to the provider?

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

A nurse is reviewing the discharge instructions for a client who had severe preeclampsia and delivered her baby at 34 weeks of gestation by cesarean birth. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse identify as an indication of magnesium sulfate toxicity?

A nurse is caring for a client with severe pre-eclampsia who is receiving magnesium sulfate. Which assessment finding would indicate that the client is experiencing magnesium toxicity?

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.