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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is a manifestation of severe preeclampsia that indicates liver involvement and can precede a seizure.
The nurse should report this finding to the provider immediately and prepare for possible delivery of the baby.
Choice A is wrong because blood pressure of 150/90 mm Hg is a sign of mild preeclampsia, not severe.Severe preeclampsia is diagnosed when the systolic pressure is 160 mm Hg or higher or the diastolic pressure is 110 mm Hg or higher.
Choice B is wrong because urine protein of 2+ is also a sign of mild preeclampsia, not severe.Severe preeclampsia is diagnosed when the urine protein is 3+ or higher.
Choice D is wrong because facial edema is a common finding in normal pregnancy and does not indicate severe preeclampsia.Other signs of severe preeclampsia include headache, blurred vision, oliguria, thrombocytopenia, and pulmonary edema.
Correct Answer is ["C","E"]
Explanation
The correct answer is choice C and E.A platelet count of 100,000/mm3 is low and indicates a risk of bleeding due to preeclampsia.A urine output of 20 mL/hour is also low and suggests kidney impairment due to magnesium sulfate therapy.
Both of these results should be reported to the provider as they may require intervention.
Choice A is wrong because a serum creatinine of 1.2 mg/dL is within the normal range of 0.6 to 1.3 mg/dL for womenand does not indicate kidney dysfunction.
Choice B is wrong because liver enzymes of 40 U/L are within the normal range of 7 to 55 U/L for women and do not indicate liver damage.
Choice D is wrong because a coagulation profile of 12 seconds is within the normal range of 11 to 13.5 seconds for women and does not indicate a clotting disorder.
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