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?

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.

Turn the client to the side.This is because turning the client to the side will prevent aspiration and maintain a patent airway during a seizure.

Some possible explanations for the other choices are:

• Choice B. Insert an oral airway.This is wrong because inserting an oral airway during a seizure can cause injury to the client’s mouth or teeth, and it can also stimulate the gag reflex and increase the risk of vomiting and aspiration.

• Choice C. Administer oxygen via face mask.This is wrong because administering oxygen via face mask during a seizure can be difficult and ineffective, as the client may not be able to breathe through the mask or may dislodge it with their movements.Oxygen can be given after the seizure has stopped, if needed.

• Choice D. Document the duration of the seizure.

This is wrong because documenting the duration of the seizure is not a priority action during a seizure.The nurse should first ensure the client’s safety and airway patency, and then document the seizure characteristics after it has ended.