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

Answer and Explanation

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.

Magnesium Sulfate Toxicity

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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.

A. “I will monitor my blood pressure at home for the next few weeks.” B. “I will report any headache, vision changes, or abdominal pain to my doctor.” C. “I will resume my normal activities as soon as I get home.” D. “I will continue to take my prenatal vitamins and iron supplements.”

Correct Answer is C

Explanation

The client should not resume normal activities as soon as she gets home because she is still at risk for complications from preeclampsia.She should rest as directed by her healthcare provider and avoid strenuous activities that may increase her blood pressure.

Choice A is wrong because monitoring blood pressure at home is a recommended practice for clients who had preeclampsia.It can help detect any signs of worsening hypertension or organ damage.

Choice B is wrong because reporting any headache, vision changes, or abdominal pain to the doctor is a crucial step to prevent serious complications from preeclampsia.These symptoms may indicate damage to the brain, eyes, or liver and require immediate medical attention.

Choice D is wrong because continuing to take prenatal vitamins and iron supplements is beneficial for the client’s recovery and health.Prenatal vitamins can provide essential nutrients that may be lacking in the diet, and iron supplements can prevent or treat anemia that may result from blood loss during delivery.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with severe pre-eclampsia who reports a severe headache and blurred vision. The nurse notes that the client has hyperreflexia with clonus. What is the most likely explanation for these findings?

Correct Answer is A

Explanation

A nurse is providing discharge instructions to a client who had pre-eclampsia and delivered a healthy baby. Which statement by the client indicates a need for further teaching?

Correct Answer is C

Explanation

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A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate infusion. Which of the following assessments is most important for the nurse to monitor?

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A nurse is providing discharge teaching to a client who had preeclampsia and delivered a healthy baby at 38 weeks of gestation. Which of the following instructions should the nurse include in the teaching?

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A nurse is reviewing the laboratory results of a client with severe pre-eclampsia who is receiving magnesium sulfate. Which finding would indicate a therapeutic level of magnesium sulfate?

A nurse is caring for a client with mild pre-eclampsia who has a blood pressure of 150/95 mmHg, proteinuria of 400 mg/24 hours, and edema of the face and hands. Which intervention is the priority for this client?

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?