A nurse is assessing a client with severe pre-eclampsia who is receiving magnesium sulfate infusion.
Which finding should alert the nurse to suspect magnesium toxicity?
Respiratory rate of 10 breaths/min
Deep tendon reflexes of 2+
Urine output of 40 mL/hour
Serum magnesium level of 6 mq/L
The Correct Answer is A
Respiratory rate of 10 breaths/min.
This is a sign of magnesium toxicity, which can occur when a client receives magnesium sulfate infusion for severe pre-eclampsia. Magnesium toxicity can cause muscle weakness, difficulty breathing, irregular heartbeats, and cardiac arrest.
Choice B is wrong because deep tendon reflexes of 2+ are normal and do not indicate magnesium toxicity.
Choice C is wrong because urine output of 40 mL/hour is adequate and does not indicate magnesium toxicity.
The minimum urine output for an adult is 30 mL/hour.
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 and does not indicate magnesium toxicity. Magnesium levels above 2.6 mEq/L can indicate hypermagnesemia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Magnesium sulfate therapy is used to prevent seizures in women with preeclampsia, a complication of pregnancy characterized by high blood pressure and organ dysfunction.Seizures are a sign of eclampsia, a severe form of preeclampsia that can be life-threatening.
Therefore, if the therapy is successful, the woman should not have any seizures.
Choice B.Absence of proteinuria is wrong because proteinuria, or excess protein in urine, is a possible sign of preeclampsia, not eclampsia.
Proteinuria may not disappear even after magnesium sulfate therapy.
Choice C.Absence of edema is wrong because edema, or swelling, is a common symptom of pregnancy and may not be related to preeclampsia or eclampsia.
Edema may not disappear even after magnesium sulfate therapy.
Choice D.Absence of headache is wrong because headache is a symptom of preeclampsia, not eclampsia.
Headache may not disappear even after magnesium sulfate therapy.
Normal ranges for blood pressure are below 140/90 mm Hg and for protein in urine are below 300 mg per 24 hours.
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.
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