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

Which of the following findings indicates magnesium toxicity?

Answer is A and C. Eclampsia is a life-threatening complication of pregnancy that causes seizures due to severe hypertension.The nurse should monitor the fetal heart rate and uterine activity continuously to assess for signs of fetal distress or placental abruption.The nurse should also maintain a dark and quiet environment to reduce stimuli that might trigger seizures.

Statement B is wrong because administering oxytocin to augment labor can increase the risk of uterine rupture and placental abruption in a patient with eclampsia.

Statement D is wrong because encouraging oral fluids and a high-protein diet can worsen the fluid retention and renal impairment in a patient with eclampsia.

Statement E is wrong because assessing for signs of placental abruption is not enough.The nurse should also monitor the vital signs, urine output, neurological status, and laboratory values of the patient with eclampsia.

Normal ranges for blood pressure are less than 120/80 mmHg for non-pregnant adults and less than 140/90 mmHg for pregnant women.Normal ranges for protein in urine are less than 150 mg/day for non-pregnant adults and less than 300 mg/day for pregnant women.

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.