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.

Administer calcium gluconate as an antidote if toxicity occurs.Magnesium sulfate is a mineral that reduces seizure risks in women with severe preeclampsia.However, it can also cause side effects and toxicity, such as respiratory depression, muscle weakness, and cardiac arrest.Calcium gluconate is an antidote that can reverse the effects of magnesium sulfate and restore normal neuromuscular function.

Choice B is wrong because magnesium sulfate does not affect blood glucose levels.

There is no need to monitor the client’s blood glucose level every 4 hours.

Choice C is wrong because the infusion should be discontinued if the client’s respiratory rate is below 12/min, not 16/min.

A low respiratory rate indicates respiratory depression, which is a sign of magnesium toxicity.

Choice D is wrong because the infusion rate should not be increased if the client’s urine output is above 30 mL/hr.Urine output should be at least 30 mL/hr while administering magnesium sulfate to prevent accumulation of the drug in the body.

Increasing the infusion rate can increase the risk of toxicity.

The correct answer is choices B, C, D, and E.These are all risk factors for pre-eclampsia according to various sources.

Choice A is wrong because age over 35 years is not a risk factor for pre-eclampsia by itself, although it may be associated with other conditions that increase the risk, such as chronic hypertension or diabetes.

Pre-eclampsia is a complication of pregnancy that involves high blood pressure, protein in the urine, and organ damage.It can affect both the mother and the fetus and can lead to serious complications such as eclampsia (seizures), placental abruption, and stillbirth.It is more common in first pregnancies, especially with a new partner, because of the immune response to the foreign fetal antigens.Obesity, diabetes mellitus, and multiple gestation are also risk factors because they increase the metabolic and vascular demands on the placenta and the mother.

Normal ranges for blood pressure and proteinuria in pregnancy are:

• Blood pressure: less than 140/90 mmHg

• Proteinuria: less than 300 mg/24 hours or less than 30 mg/dL on a random urine sample