A nurse is assessing a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion.

Which of the following findings should alert the nurse to suspect magnesium toxicity?

Respiratory rate 10/min

Urine output 40 mL/hr

Patellar reflex 2+

Serum magnesium level 4.5 mEq/L

Answer and Explanation

The Correct Answer is A

Respiratory rate 10/min. This indicates muscle weakness and difficulty breathing, which are symptoms of magnesium 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 reflects muscle weakness and nerve 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.

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Correct Answer is ["A","B","C","E"]

Explanation

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)

A. Administer oxygen via face mask B. Turn the client to the side C. Insert an oral airway D. Give a loading dose of magnesium sulfate

Correct Answer is B

Explanation

Turn the client to the side.This is because turning the client to the side will prevent aspiration of secretions or vomitus and maintain a patent airway during a seizure.

This is the most important and immediate action to take for a client with eclampsia who is having a tonic-clonic seizure.

Choice A is wrong because administering oxygen via face mask is not the first priority and may not be feasible during a seizure.Oxygen therapy may be indicated after the seizure to improve oxygenation and fetal well-being.

Choice C is wrong because inserting an oral airway is contraindicated during a seizure as it may cause injury to the oral mucosa or trigger a gag reflex.An oral airway may be used after the seizure if the client is unconscious and has a compromised airway.

Choice D is wrong because giving a loading dose of magnesium sulfate is not the first action to take, although it is an important intervention to prevent further seizures and lower blood pressure in eclampsia.Magnesium sulfate should be administered intravenously after securing the airway and ensuring adequate ventilation.

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A nurse is assessing a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should alert the nurse to suspect magnesium toxicity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is caring for a client with eclampsia who is having a tonic-clonic seizure. Which action should the nurse take first?

Correct Answer is B

Explanation

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A nurse is assessing a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion.

Which of the following findings should alert the nurse to suspect magnesium toxicity?