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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Related Questions
Correct Answer is C
Explanation
Deep tendon reflexes.
The nurse should monitor the client’s deep tendon reflexes to assess for signs of magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.Magnesium sulfate is given to prevent seizures in clients with severe preeclampsia, but it can also have adverse effects on the neuromuscular system.
Choice A is wrong because blood pressure is not the most important assessment for a client receiving magnesium sulfate.
Blood pressure is a manifestation of preeclampsia, but it does not indicate magnesium toxicity.
Choice B is wrong because urine output is not the most important assessment for a client receiving magnesium sulfate.
Urine output should be at least 25 to 30 mL/hr to promote adequate excretion of magnesium, but it does not reflect the level of magnesium in the blood.
Choice D is wrong because fetal heart rate is not the most important assessment for a client receiving magnesium sulfate.
Fetal heart rate is important to monitor for signs of fetal distress, but it does not indicate maternal magnesium toxicity.
Correct Answer is C
Explanation
Encourage bed rest in a left lateral position.
This is because bed rest can lower blood pressure and improve blood flow to the placenta and the fetus.The left lateral position reduces pressure on the inferior vena cava, a large vein that carries blood from the lower body to the heart.
Choice A is wrong because magnesium sulfate is used to prevent seizures in severe preeclampsia or eclampsia, not mild preeclampsia.
Choice B is wrong because monitoring the fetal heart rate and movement is important, but not the priority for this client.
Choice D is wrong because educating the client about the signs of eclampsia is not urgent and may not prevent the progression of preeclampsia.Some signs of eclampsia are severe headaches, blurred vision, nausea, vomiting, abdominal pain and seizures.
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