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","B","D","E"]
Explanation
The correct answer is choice A, B, D and E. These are all signs of severe preeclampsia that indicate organ damage and require immediate medical attention.According to Mayo Clinic, preeclampsia is a complication of pregnancy that causes high blood pressure, protein in the urine, or other signs of organ damage after 20 weeks of gestation.
Choice A is correct because epigastric pain can indicate liver damage or bleeding in the abdomen due to preeclampsia.
Choice B is correct because blurred vision or light sensitivity can indicate brain damage or increased pressure in the skull due to preeclampsia.
Choice C is wrong because facial edema is a common symptom of normal pregnancy and does not necessarily indicate preeclampsia.
Choice D is correct because hyperreflexia can indicate nervous system damage or increased pressure in the skull due to preeclampsia.
Choice E is correct because oliguria can indicate kidney damage or decreased blood flow to the kidneys due to preeclampsia.
Correct Answer is ["C","D"]
Explanation
The correct answer is choice C and D.Epigastric pain and decreased fetal movement are signs of severe pre-eclampsia that indicate damage to the liver and placenta respectively.These symptoms should be reported to the health care provider immediately as they may lead to serious complications such as eclampsia, HELLP syndrome, placental abruption or fetal growth restriction.
Choice A is wrong because sudden weight gain is a common symptom of mild pre-eclampsia that does not necessarily require immediate attention.However, it should be monitored regularly along with blood pressure and urine protein levels.
Choice B is wrong because swelling of the face and hands is also a common symptom of mild pre-eclampsia that does not indicate severe organ damage.It may be caused by fluid retention or edema.
Choice E is wrong because vaginal bleeding is not a typical symptom of pre-eclampsia.It may be a sign of other pregnancy complications such as placenta previa, placental abruption or cervical infection.
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