A nurse is caring for a client with eclampsia who is receiving magnesium sulfate intravenously.

Which of the following findings indicates magnesium toxicity?

Turn the client to the side.This is because turning the client to the side will prevent aspiration and maintain a patent airway during a seizure.

Some possible explanations for the other choices are:

• Choice B. Insert an oral airway.This is wrong because inserting an oral airway during a seizure can cause injury to the client’s mouth or teeth, and it can also stimulate the gag reflex and increase the risk of vomiting and aspiration.

• Choice C. Administer oxygen via face mask.This is wrong because administering oxygen via face mask during a seizure can be difficult and ineffective, as the client may not be able to breathe through the mask or may dislodge it with their movements.Oxygen can be given after the seizure has stopped, if needed.

• Choice D. Document the duration of the seizure.

This is wrong because documenting the duration of the seizure is not a priority action during a seizure.The nurse should first ensure the client’s safety and airway patency, and then document the seizure characteristics after it has ended.

Maintain a dark and quiet environment.This intervention helps to reduce sensory stimulation and prevent seizures in a client with eclampsia.

Choice A is wrong becausemonitoring fetal heart rate and uterine activity continuouslyis not a priority intervention for a client with eclampsia.The priority is to prevent seizures and control blood pressure.

Choice B is wrong becauseadministering oxytocin to augment laboris contraindicated in a client with eclampsia.Oxytocin can increase blood pressure and cause uterine hyperstimulation, which can worsen the condition and endanger the mother and the fetus.

Choice D is wrong becauseencouraging oral fluids and a high-protein dietis not appropriate for a client with eclampsia.

The client should be kept NPO to prevent aspiration in case of a seizure.A high-protein diet can increase the risk of renal failure and hepatic dysfunction.

Choice E is wrong becauseassessing for signs of placental abruptionis not a specific intervention for a client with eclampsia.Placental abruption can occur as a complication of eclampsia, but it is not the main focus of care.