A nurse is caring for a client with eclampsia who is receiving magnesium sulfate intravenously.
Which of the following findings indicates magnesium toxicity?
Hyperreflexia
Tachycardia
Oliguria
Hypertension
The Correct Answer is C
Fetal heart rate decelerations indicate a possible compromise of fetal oxygenation and should be reported to the provider immediately. Decelerations can be caused by various factors such as cord compression, uterine hyperstimulation, maternal hypotension, or placental abruption .
Choice A is wrong because a fetal heart rate of 140 beats per minute is within the normal range of 110 to 160 beats per minute .
Choice B is wrong because uterine contractions every 10 minutes are not abnormal in a client with severe pre-eclampsia who is receiving magnesium sulfate. Magnesium sulfate is used to prevent seizures and lower blood pressure in pre-eclampsia, but it does not stop labor .
Choice D is wrong because uterine contractions lasting 60 seconds are not a sign of …
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The target blood pressure goal for a client with severe pre-eclampsia is less than 160/110 mmHg.
This is because lowering the blood pressure too much or too fast can compromise the placental perfusion and fetal oxygenation.
Choice A is wrong because it is the target blood pressure goal for a client with chronic hypertension or gestational hypertension without severe features.
Choice B is wrong because it is the target blood pressure goal for a client with mild pre-eclampsia.
Choice D is wrong because it is too high and can increase the risk of maternal and fetal complications such as stroke, eclampsia, placental abruption, and fetal growth restriction.
Normal blood pressure ranges are less than 120/80 mmHg for systolic and diastolic pressures respectively.
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is choice A, B, C and E.The nurse should monitor the client’s deep tendon reflexes hourly because magnesium sulfate can cause neuromuscular blockade and decreased reflexes.The nurse should keep calcium gluconate readily available because it is the antidote for magnesium toxicity.The nurse should maintain a urine output of at least 40 mL/hr because magnesium is excreted by the kidneys and low urine output can indicate renal impairment or fluid overload.The nurse should check the client’s blood pressure every 15 minutes because magnesium sulfate can cause hypotension and preeclampsia can cause hypertension.
Choice D is wrong because the medication should not be infused via a peripheral IV line, but rather through a central line or a large-bore IV catheter to prevent tissue damage.
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