A nurse is caring for a client who has eclampsia and is receiving magnesium sulfate and hydralazine.

The client’s blood pressure is 150/90 mmHg, pulse is 88/min, respirations are 18/min, and oxygen saturation is 97%.

The nurse notes that the client’s deep tendon reflexes are absent.

Which of the following actions should the nurse take?

Stop the magnesium sulfate infusion

Increase the rate of the hydralazine infusion

Administer calcium gluconate IV push

Prepare for immediate delivery of the fetus

Answer and Explanation

The Correct Answer is A

Stop the magnesium sulfate infusion.

The client is showing signs of magnesium toxicity, such as absent deep tendon reflexes, which can lead to respiratory depression and cardiac arrest.

Magnesium sulfate is an anticonvulsant that is used to prevent seizures in eclampsia, but it can also cause vasodilation and hypotension.

The nurse should stop the infusion and monitor the client’s vital signs and neurological status.

Choice B. Increase the rate of the hydralazine infusion is wrong because hydralazine is an antihypertensive that lowers blood pressure.

The client’s blood pressure is already within the normal range for eclampsia (140/90 to 160/110 mmHg), so increasing the rate of hydralazine could cause hypotension and compromise placental perfusion.

Choice C. Administer calcium gluconate IV push is wrong because calcium gluconate is an antidote for magnesium toxicity, but it should not be given IV push.

It should be given slowly over 10 to 20 minutes to avoid cardiac arrhythmias and bradycardia.

Choice D. Prepare for immediate delivery of the fetus is wrong because delivery of the fetus is not indicated at this time.

The client’s vital signs are stable and there is no evidence of fetal distress or placental abruption.

Delivery of the fetus is the definitive treatment for eclampsia, but it should be done when the maternal and fetal conditions are optimal.

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Correct Answer is A

Explanation

The client has no seizures.Magnesium sulfate therapy is used to prevent seizures in women with preeclampsia and eclampsia.Seizures are a life-threatening complication of eclampsia and indicate a failure of therapy.

Choice B is wrong because diuresis is not a goal of magnesium sulfate therapy.Diuresis may indicate fluid overload or renal impairment, which are complications of preeclampsia and eclampsia.

Choice C is wrong because improved fetal movement is not a direct outcome of magnesium sulfate therapy.Fetal movement may be affected by many factors, such as gestational age, maternal position, and fetal well-being.

Choice D is wrong because increased platelet count is not a result of magnesium sulfate therapy.Platelet count may be decreased in preeclampsia and eclampsia due to disseminated intravascular coagulation, which is a serious complication that requires prompt treatment.

Normal ranges for blood pressure are less than 140/90 mm Hg, for proteinuria are less than 300 mg/24 hours, for platelet count are 150,000 to 400,000/mm3, and for serum magnesium are 1.5 to 2.5 mEq/L.

A. Respiratory rate of 10 breaths/min B. Deep tendon reflexes of 2+ C. Urine output of 40 mL/hour D. Serum magnesium level of 6 mq/L

Correct Answer is A

Explanation

Respiratory rate of 10 breaths/min.

This is a sign ofmagnesium toxicity, which can occur when a client receives magnesium sulfate infusion for severe pre-eclampsia.Magnesium toxicity can causemuscle weakness,difficulty breathing,irregular heartbeats, andcardiac 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

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client who has eclampsia. Which of the following outcomes indicates that the therapy is successful?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory results of a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following results should the nurse notify the provider about? (Select all that apply.)

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with eclampsia. Which of the following findings indicates a therapeutic response?

A nurse is caring for a client with eclampsia who is receiving magnesium sulfate and has a magnesium level of 10 mg/dL. Which of the following medications should the nurse have available as an antidote?

A nurse is caring for a client with eclampsia who is having a tonic-clonic seizure. Which action should the nurse take first?

A nurse is providing discharge teaching to a client who had pre-eclampsia and delivered a healthy newborn. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse identify as an indication of magnesium sulfate toxicity?

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia. Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.

A nurse is teaching a pregnant client about the risk factors for pre-eclampsia. Which of the following should the nurse include? (Select all that apply).