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?
Loss of reflexes
Headache
Nausea
Blurred vision
The Correct Answer is A
According to Mayo Clinic, loss of reflexes is a sign of magnesium toxicity and requires immediate intervention.
Other signs of magnesium toxicity include:
• Decreased urine output
• Difficulty breathing
• Drowsiness or confusion
• Low blood pressure
• Slow heart rate
• Weakness
Choice B is wrong because headache is not a sign of magnesium toxicity.
It may be a symptom of preeclampsia or other conditions, but it does not indicate an overdose of magnesium sulfate.
Choice C is wrong because nausea is not a sign of magnesium toxicity.
It may be a side effect of magnesium sulfate or a symptom of preeclampsia or other conditions, but it does not indicate an overdose of magnesium sulfate.
Choice D is wrong because blurred vision is not a sign of magnesium toxicity.
It may be a symptom of preeclampsia or other conditions, but it does not indicate an overdose of magnesium sulfate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
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.
Correct Answer is C
Explanation
The target blood pressure goal for a client with severe pre-eclampsia is less than 160/110 mmHg.
This is because lowering the blood pressure too much or too fast can compromise the placental perfusion and fetal oxygenation.
Choice A is wrong because it is the target blood pressure goal for a client with chronic hypertension or gestational hypertension without severe features.
Choice B is wrong because it is the target blood pressure goal for a client with mild pre-eclampsia.
Choice D is wrong because it is too high and can increase the risk of maternal and fetal complications such as stroke, eclampsia, placental abruption, and fetal growth restriction.
Normal blood pressure ranges are less than 120/80 mmHg for systolic and diastolic pressures respectively.
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