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?
Respiratory rate 10/min
Urine output 40 mL/hr
Patellar reflex 2+
Serum magnesium level 4.5 mEq/L
The Correct Answer is A
Respiratory rate 10/min. This indicates muscle weakness and difficulty breathing, which are symptoms of magnesium toxicity. Magnesium sulfate is a medication that can cause magnesium overdose if given in excess or if the patient has impaired kidney function.
Choice B. Urine output 40 mL/hr is wrong because this is within the normal range for urine output, which is 30 to 50 mL/hr. Urine output may decrease in severe cases of magnesium toxicity due to urine retention.
Choice C. Patellar reflex 2+ is wrong because this is a normal finding for the knee-jerk reflex. A low or absent patellar reflex may indicate magnesium toxicity, as it reflects muscle weakness and nerve dysfunction.
Choice D. Serum magnesium level 4.5 mEq/L is wrong because this is within the normal range for serum magnesium, which is 1.7 to 2.3 mEq/L. Serum magnesium levels above 2.6 mEq/L can indicate hypermagnesemia or magnesium overdose.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Respiratory rate of 10 breaths/minute.This indicates that the client is experiencingmagnesium toxicity, which can causemuscle weakness,difficulty breathing, andcardiac arrest.The normal respiratory rate for adults is 12 to 20 breaths/minute.
Choice B is wrong because deep tendon reflexes of 2+ are normal and do not indicate magnesium toxicity.
Choice C is wrong because urinary output of 40 mL/hour is within the normal range of 30 to 50 mL/hour.Magnesium toxicity can cause urine retention, not increased output.
Choice D is wrong because serum magnesium level of 6 mEq/L is within the normal range of 1.7 to 2.3 mEq/L.Magnesium toxicity occurs when the level is above 2.6 mEq/L.
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.
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