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.
Nursing Test Bank
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 C
Explanation
This is a manifestation of severe preeclampsia that indicates liver involvement and can precede a seizure.
The nurse should report this finding to the provider immediately and prepare for possible delivery of the baby.
Choice A is wrong because blood pressure of 150/90 mm Hg is a sign of mild preeclampsia, not severe.Severe preeclampsia is diagnosed when the systolic pressure is 160 mm Hg or higher or the diastolic pressure is 110 mm Hg or higher.
Choice B is wrong because urine protein of 2+ is also a sign of mild preeclampsia, not severe.Severe preeclampsia is diagnosed when the urine protein is 3+ or higher.
Choice D is wrong because facial edema is a common finding in normal pregnancy and does not indicate severe preeclampsia.Other signs of severe preeclampsia include headache, blurred vision, oliguria, thrombocytopenia, and pulmonary edema.
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