A nurse is caring for a client with severe pre-eclampsia who is receiving magnesium sulfate.
Which of the following findings would indicate magnesium toxicity and require immediate intervention?
Urinary output of 25 mL/hour
Respiratory rate of 14 breaths/minute
Deep tendon reflexes 1+
Serum magnesium level of 6 mg/dL
The Correct Answer is A
A. Urinary output of 25 mL/hour. This indicates magnesium toxicity and requires immediate intervention because it means the kidneys are not functioning properly and magnesium is not being excreted. Magnesium toxicity can cause life-threatening complications such as respiratory depression, cardiac arrest, and coma.
B. Respiratory rate of 14 breaths/minute is normal and does not indicate magnesium toxicity. A respiratory rate of less than 12 breaths/minute or more than 20 breaths/minute would be abnormal and require further assessment.
C. Deep tendon reflexes 1+ are normal and do not indicate magnesium toxicity. A loss of deep tendon reflexes or clonus would indicate magnesium toxicity and require immediate intervention.
D. Serum magnesium level of 6 mg/dL is within the therapeutic range for preeclampsia and does not indicate magnesium toxicity.
The therapeutic range for preeclampsia is 4 to 7 mg/dL. A serum magnesium level of more than 8 mg/dL would indicate magnesium toxicity and require immediate intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The most likely explanation for the client's findings of severe headache, blurred vision, hyperreflexia, and clonus in the context of severe pre-eclampsia is A. Cerebral edema.
Pre-eclampsia is a pregnancy-related condition characterized by high blood pressure (hypertension) and signs of organ damage, most commonly affecting the liver and kidneys. Severe pre-eclampsia can lead to complications such as eclampsia, which is characterized by seizures. The symptoms described by the client, including severe headache and blurred vision, are consistent with neurological manifestations associated with severe pre-eclampsia.
Hyperreflexia refers to an exaggerated reflex response, and clonus refers to rhythmic contractions of a muscle when it is passively stretched. Both hyperreflexia and clonus are indicative of central nervous system (CNS) hyperexcitability. Cerebral edema, which is the swelling of the brain due to fluid accumulation, can lead to increased intracranial pressure and neurological symptoms such as headache, vision changes, hyperreflexia, and clonus.
While other complications such as pulmonary edema (B), hemolysis (C), and thrombocytopenia (D) can occur in severe pre-eclampsia, they are not directly associated with the reported symptoms of severe headache, blurred vision, hyperreflexia, and clonus.
Pre-eclampsia is a pregnancy-related condition characterized by high blood pressure (hypertension) and signs of organ damage, most commonly affecting the liver and kidneys. Severe pre-eclampsia can lead to complications such as eclampsia, which is characterized by seizures. The symptoms described by the client, including severe headache and blurred vision, are consistent with neurological manifestations associated with severe pre-eclampsia.
Hyperreflexia refers to an exaggerated reflex response, and clonus refers to rhythmic contractions of a muscle when it is passively stretched. Both hyperreflexia and clonus are indicative of central nervous system (CNS) hyperexcitability. Cerebral edema, which is the swelling of the brain due to fluid accumulation, can lead to increased intracranial pressure and neurological symptoms such as headache, vision changes, hyperreflexia, and clonus.
While other complications such as pulmonary edema (B), hemolysis (C), and thrombocytopenia (D) can occur in severe pre-eclampsia, they are not directly associated with the reported symptoms of severe headache, blurred vision, hyperreflexia, and clonus.
Correct Answer is ["B","C","D"]
Explanation
The correct answer is choice B, C and D. These results indicate hepatic involvement because they are elevated above the normal ranges.According to, the normal ranges for AST, ALT and LDH are:
• AST: 8 to 48 U/L
• ALT: 7 to 55 U/L
• LDH: 122 to 222 U/L
Choice A is wrong because serum creatinine is not a marker of liver function, but of kidney function.The normal range for serum creatinine is 0.6 to 1.3 mg/dL for adults.
Choice E is wrong because platelet count is not a marker of liver function, but of blood clotting ability.The normal range for platelet count is 150 to 450 x 10^9/L.
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