A nurse is reviewing the laboratory results of a client who has mild preeclampsia.

Which of the following findings would indicate a need for further evaluation?

Platelet count of 150,000/mm3

Serum creatinine of 1.2 mg/dL

Proteinuria of 1+ on dipstick

Serum albumin of 3.5 g/dL

Answer and Explanation

The Correct Answer is B

Serum creatinine of 1.2 mg/dL. This indicates a need for further evaluation because it is above the normal range of 0.6 to 1.1 mg/dL for women and suggests kidney impairment. Preeclampsia can affect the kidneys and other organs.

Choice A is wrong because a platelet count of 150,000/mm3 is within the normal range of 150,000 to 450,000/mm3.

Choice C is wrong because proteinuria of 1+ on dipstick is expected in mild preeclampsia.

Choice D is wrong because serum albumin of 3.5 g/dL is within the normal range of 3.4 to 5.4 g/dL.

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Correct Answer is C

Explanation

Deep tendon reflexes.

The nurse should monitor the client’s deep tendon reflexes to assess for signs of magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.Magnesium sulfate is given to prevent seizures in clients with severe preeclampsia, but it can also have adverse effects on the neuromuscular system.

Calcium Gluconate Is The Antidote For Magnesium Sulfate Toxicity

Choice A is wrong because blood pressure is not the most important assessment for a client receiving magnesium sulfate.

Blood pressure is a manifestation of preeclampsia, but it does not indicate magnesium toxicity.

Choice B is wrong because urine output is not the most important assessment for a client receiving magnesium sulfate.

Urine output should be at least 25 to 30 mL/hr to promote adequate excretion of magnesium, but it does not reflect the level of magnesium in the blood.

Choice D is wrong because fetal heart rate is not the most important assessment for a client receiving magnesium sulfate.

Fetal heart rate is important to monitor for signs of fetal distress, but it does not indicate maternal magnesium toxicity.

A. Urinary output of 25 mL/hour B. Respiratory rate of 14 breaths/minute C. Deep tendon reflexes 1+ D. Serum magnesium level of 6 mg/dL

Correct Answer is A

Explanation

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.

Magnesium Sulfate Toxicity

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A nurse is reviewing the laboratory results of a client who has mild preeclampsia. Which of the following findings would indicate a need for further evaluation?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate infusion. Which of the following assessments is most important for the nurse to monitor?

Correct Answer is C

Explanation

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?

Correct Answer is A

Explanation

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A nurse is reviewing the laboratory results of a client who has mild preeclampsia.

Which of the following findings would indicate a need for further evaluation?