A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia.

Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.

Deep tendon reflexes

Respiratory rate

Urine output

Fetal heart rate

Serum magnesium level

Answer and Explanation

Correct Answer : A,B,C,E

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)

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Correct Answer is A

Explanation

Respiratory rate 10/min.This indicatesmuscle weaknessanddifficulty breathing, which are symptoms ofmagnesium toxicity.Magnesium sulfate is a medication that can cause magnesium overdose if given in excess or if the patient has impaired kidney function.

Choice B.Urine output 40 mL/hr is wrong because this is within the normal range for urine output, which is 30 to 50 mL/hr.Urine output may decrease in severe cases of magnesium toxicity due to urine retention.

Choice C. Patellar reflex 2+ is wrong because this is a normal finding for the knee-jerk reflex.A low or absent patellar reflex may indicate magnesium toxicity, as it reflectsmuscle weaknessandnerve dysfunction.

Choice D.Serum magnesium level 4.5 mEq/L is wrong because this is within the normal range for serum magnesium, which is 1.7 to 2.3 mEq/L.Serum magnesium levels above 2.6 mEq/L can indicate hypermagnesemia or magnesium overdose.

A. “I should avoid foods that are high in sodium.” B. “I should lie on my left side for at least 2 hours a day.” C. “I should check my blood pressure at home every day.” D. “I should take a baby aspirin every day as prescribed.”

Correct Answer is D

Explanation

“I should take a baby aspirin every day as prescribed.” Taking a baby aspirin daily has been shown to reduce the risk of developing preeclampsia by about 15%.If you have risk factors for preeclampsia, your healthcare provider may recommend starting aspirin in early pregnancy (by 12 weeks gestation).

Choice A is wrong because avoiding foods that are high in sodium does not prevent preeclampsia.Sodium intake does not affect blood pressure in pregnancy.

Choice B is wrong because lying on your left side for at least 2 hours a day does not prevent preeclampsia.However, lying on your left side may help improve blood flow to your placenta and your baby.

Choice C is wrong because checking your blood pressure at home every day does not prevent preeclampsia.However, monitoring your blood pressure at home may help detect signs of preeclampsia early and alert you to seek medical attention if needed.

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A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia. Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia.

Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.