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 D

Explanation

“I will resume my normal activities as soon as possible.” This statement indicates a need for further teaching because a woman who had severe pre-eclampsia should rest more often and avoid strenuous activities until her blood pressure is normal and stable.She should also follow up with her doctor regularly and monitor her blood pressure at home.

Choice A is wrong because it is important to monitor blood pressure at home for a few weeks after having pre-eclampsia.

This can help detect any signs of worsening hypertension or organ damage.

Choice B is wrong because it is advisable to call the doctor if there are any headaches or vision changes, as these could be signs of brain injury or eclampsia.

Eclampsia is a serious complication of pre-eclampsia that causes seizures.

Choice C is wrong because some over-the-counter pain medications, such as ibuprofen, can increase blood pressure and should be avoided by women with pre-eclampsia.However, acetaminophen (Tylenol) is usually safe to take for mild pain relief.

Normal ranges for blood pressure during pregnancy are less than 140/90 mmHg.Normal ranges for protein in urine during pregnancy are less than 300 mg in 24 hours.

A. Hydralazine B. Nifedipine C. Labetalol D. Methyldopa

Correct Answer is C

Explanation

Labetalol is an antihypertensive drug that can lower blood pressure in pregnant women with preeclampsia.Preeclampsia is a condition that causes high blood pressure and proteinuria after 20 weeks of gestation.

Choice A is wrong because hydralazine is not recommended as a first-line treatment for preeclampsia due to its potential adverse effects on maternal and fetal outcomes.

Choice B is wrong because nifedipine is not licensed for use in pregnancy and may interact with magnesium sulfate, which is an anticonvulsant medication used to prevent or treat seizures in severe preeclampsia.

Choice D is wrong because methyldopa is not effective for acute blood pressure control and may cause adverse effects such as depression, sedation, and hemolytic anemia.

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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

A nurse is providing discharge instructions to a client who had severe pre-eclampsia and delivered a healthy baby at 34 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is D

Explanation

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Correct Answer is C

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.