A nurse is assessing a client who has eclampsia and is receiving magnesium sulfate IV.

Which of the following findings should indicate to the nurse that the client is experiencing magnesium toxicity?

The correct answer is choice B. Platelets 80,000/mm3.This is because HELLP syndrome is a severe form of preeclampsia characterized byHemolysis,Elevated Liver enzymes, andLow Platelets.Platelets are blood cells that help with clotting, and a normal range is 150,000 to 450,000/mm3.A low platelet count (<100,000/mm3) indicates a risk of bleeding and organ damage.

Choice A is wrong because hemoglobin 12 g/dL is within the normal range for pregnant women (11 to 16 g/dL).Hemoglobin is a protein in red blood cells that carries oxygen, and hemolysis is the breakdown of red blood cells.

Choice C is wrong because AST 15 U/L is within the normal range for women (10 to 35 U/L).AST is a liver enzyme that indicates liver function, and elevated liver enzymes (>70 U/L) indicate liver damage.

Choice D is wrong because LDH 90 U/L is within the normal range for women (85 to 225 U/L).LDH is another liver enzyme that indicates liver function, and elevated LDH (>600 U/L) indicates liver damage.

Choice A is correct because magnesium sulfate is excreted in the urine and a decreased urine output places the client at risk for magnesium toxicity.The nurse should monitor the client’s urine output hourly and report any decrease to the provider.

Choice B is wrong because hyperactive (3+ or 4+) deep tendon reflexes are a common physical finding of preeclampsia or eclampsia and do not require an action.The nurse should check the client’s deep tendon reflexes more frequently than every 4 hours to detect any signs of magnesium toxicity, such as absent or hypoactive reflexes.

Choice C is correct because calcium gluconate is the antidote for magnesium toxicity and should be readily available in case of respiratory depression, cardiac arrest, or other signs of overdose.The nurse should administer 10 mL of 10% calcium gluconate IV push over 3 to 5 minutes if needed.

Choice D is correct because magnesium sulfate should be administered via a piggyback infusion using an infusion pump to ensure accurate and safe delivery.The nurse should not administer magnesium sulfate as a bolus or through a primary IV line.

Choice E is wrong because the infusion rate of magnesium sulfate should not be titrated according to the client’s blood pressure, but according to the client’s serum magnesium level, which should range from 4 to 7 mEq/L.The nurse should notify the provider of any low or high serum magnesium level and adjust the infusion rate accordingly.The nurse should also administer antihypertensive medications other than magnesium for sustained hypertension.

Normal ranges:

• Urine output: at least 30 mL/hour

• Deep tendon reflexes: 1+ or 2+

• Respiratory rate: 12 to 20 breaths/minute

• Serum magnesium level: 4 to 7 mEq/L

• Blood pressure: less than 140/90 mm Hg