A nurse is educating a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously about the possible side effects of the medication.
Which of the following statements should the nurse include in the teaching?
“You may feel warm and flushed while receiving this medication.”
“You may experience increased thirst and dry mouth while receiving this medication.”
“You may have difficulty sleeping and feel restless while receiving this medication.”
“You may notice swelling and redness at the infusion site while receiving this medication.”
The Correct Answer is A
“You may feel warm and flushed while receiving this medication.” This is a common side effect of magnesium sulfate therapy, which is used to prevent seizures in women with severe pre-eclampsia. Magnesium sulfate can also help prolong a pregnancy for up to two days by relaxing the uterus.
Choice B is wrong because magnesium sulfate can cause fluid retention and swelling, not dehydration. Choice C is wrong because magnesium sulfate can cause drowsiness and lethargy, not insomnia and restlessness. Choice D is wrong because magnesium sulfate can cause decreased blood pressure and heart rate, not inflammation and infection at the infusion site.
Normal ranges for blood pressure are below 140/90 mm Hg, for platelet count are 150,000 to 450,000 per microliter of blood, and for protein in urine are less than 300 milligrams per day.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is choice A, B, C and E.The nurse should monitor for magnesium toxicity by assessing the deep tendon reflexes, respiratory rate, urine output and serum magnesium level of the client who has severe preeclampsia and is receiving magnesium sulfate IV.Magnesium toxicity can cause life-threatening complications such as hypotension, areflexia (loss of DTRs), respiratory depression, respiratory arrest, oliguria, shortness of breath, chest pains, slurred speech and cardiac arrest.The nurse should also have calcium chloride ready as an antidote for magnesium toxicity.
Choice D is wrong because fetal heart rate is not a direct indicator of magnesium toxicity.However, the nurse should still monitor the fetal heart rate and uterine activity per the Electronic Fetal Monitoring (EFM) Guideline.
Normal ranges for the assessments are:
• Deep tendon reflexes: 1+ to 4+ (normal to hyperactive)
• Respiratory rate: 12 to 20 breaths per minute
• Urine output: at least 30 mL per hour
• Serum magnesium level: 4 to 7 mg/dL (therapeutic range for preeclampsia)
Correct Answer is D
Explanation
The client should have a follow-up visit with the provider in a week.This is because preeclampsia can persist or develop after delivery and requires close monitoring of blood pressure and signs of organ injury.
Choice A is wrong because vaginal bleeding is normal after delivery and does not indicate a complication of preeclampsia.
Choice B is wrong because the client should not stop taking blood pressure medication without consulting the provider.Preeclampsia can cause hypertension that may need treatment even after delivery.
Choice C is wrong because breastfeeding is not contraindicated for women with preeclampsia.Breastfeeding may even lower blood pressure and help the uterus contract.
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