A nurse is assessing a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion.

Which of the following findings should alert the nurse to suspect magnesium toxicity?

The correct answer is choice A and C. A client with HELLP syndrome is at risk for bleeding, liver damage, and fluid overload or transfusion reaction.Therefore, the nurse should monitor vital signs and urine output to assess for signs of shock, hemorrhage, or renal failure.The nurse should also check for signs of fluid overload or transfusion reaction such as dyspnea, crackles, edema, fever, chills, or rash.

Choice B is wrong because corticosteroids are not indicated for clients with HELLP syndrome unless they have severe thrombocytopenia or need to delay delivery for fetal lung maturity.Corticosteroids may worsen the liver function and increase the risk of infection.

Choice D is wrong because encouraging oral intake of fluids and electrolytes may exacerbate fluid overload and hypertension in clients with HELLP syndrome.Fluid restriction and diuretics may be prescribed to reduce the risk of pulmonary edema and cerebral edema.

Choice E is wrong because maintaining bed rest and a quiet environment may not be sufficient to prevent the progression of HELLP syndrome.The definitive treatment for HELLP syndrome is delivery of the fetus and placenta as soon as possible.Bed rest and a quiet environment may help reduce blood pressure and stress, but they are not the main interventions for this condition.

“I will resume my normal activities as soon as possible.” This statement indicates a need for further teaching because a woman who had severe pre-eclampsia should rest more often and avoid strenuous activities until her blood pressure is normal and stable.She should also follow up with her doctor regularly and monitor her blood pressure at home.

Choice A is wrong because it is important to monitor blood pressure at home for a few weeks after having pre-eclampsia.

This can help detect any signs of worsening hypertension or organ damage.

Choice B is wrong because it is advisable to call the doctor if there are any headaches or vision changes, as these could be signs of brain injury or eclampsia.

Eclampsia is a serious complication of pre-eclampsia that causes seizures.

Choice C is wrong because some over-the-counter pain medications, such as ibuprofen, can increase blood pressure and should be avoided by women with pre-eclampsia.However, acetaminophen (Tylenol) is usually safe to take for mild pain relief.

Normal ranges for blood pressure during pregnancy are less than 140/90 mmHg.Normal ranges for protein in urine during pregnancy are less than 300 mg in 24 hours.