A nurse is monitoring a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.

Which of the following signs indicates magnesium toxicity and requires immediate intervention?

Choice A rationale: Magnesium sulfate acts as a central nervous system depressant. In HELLP syndrome and preeclampsia, its primary therapeutic purpose is to provide seizure prophylaxis by decreasing neuromuscular irritability and excitability.

Choice B rationale: While magnesium sulfate may cause slight vasodilation, it is not an antihypertensive agent. Elevated blood pressure in HELLP syndrome is managed with specific medications like hydralazine, labetalol, or nifedipine.

Choice C rationale: Magnesium sulfate does not function as a diuretic. In fact, adequate urine output is a critical assessment for magnesium toxicity, as the medication is primarily excreted by the kidneys.

Choice D rationale: Magnesium sulfate has no direct effect on bone marrow or platelet production. HELLP syndrome is characterized by low platelets; improvement usually only occurs following delivery or resolving the underlying condition.

Answer is A and C. Eclampsia is a life-threatening complication of pregnancy that causes seizures due to severe hypertension.The nurse should monitor the fetal heart rate and uterine activity continuously to assess for signs of fetal distress or placental abruption.The nurse should also maintain a dark and quiet environment to reduce stimuli that might trigger seizures.

Statement B is wrong because administering oxytocin to augment labor can increase the risk of uterine rupture and placental abruption in a patient with eclampsia.

Statement D is wrong because encouraging oral fluids and a high-protein diet can worsen the fluid retention and renal impairment in a patient with eclampsia.

Statement E is wrong because assessing for signs of placental abruption is not enough.The nurse should also monitor the vital signs, urine output, neurological status, and laboratory values of the patient with eclampsia.

Normal ranges for blood pressure are less than 120/80 mmHg for non-pregnant adults and less than 140/90 mmHg for pregnant women.Normal ranges for protein in urine are less than 150 mg/day for non-pregnant adults and less than 300 mg/day for pregnant women.