A nurse is assessing a client with severe pre-eclampsia who is receiving magnesium sulfate infusion.
Which finding should alert the nurse to suspect magnesium toxicity?
Respiratory rate of 10 breaths/min
Deep tendon reflexes of 2+
Urine output of 40 mL/hour
Serum magnesium level of 6 mq/L
The Correct Answer is A
Respiratory rate of 10 breaths/min.
This is a sign of magnesium toxicity, which can occur when a client receives magnesium sulfate infusion for severe pre-eclampsia. Magnesium toxicity can cause muscle weakness, difficulty breathing, irregular heartbeats, and cardiac arrest.
Choice B is wrong because deep tendon reflexes of 2+ are normal and do not indicate magnesium toxicity.
Choice C is wrong because urine output of 40 mL/hour is adequate and does not indicate magnesium toxicity.
The minimum urine output for an adult is 30 mL/hour.
Choice D is wrong because serum magnesium level of 6 mEq/L is within the normal range of 1.7 to 2.3 mEq/L and does not indicate magnesium toxicity. Magnesium levels above 2.6 mEq/L can indicate hypermagnesemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“You may feel warm and flushed while receiving this medication.” This is a common side effect of magnesium sulfate therapy, which is used to prevent seizures in women with severe pre-eclampsia.Magnesium sulfate can also help prolong a pregnancy for up to two days by relaxing the uterus.
Choice B is wrong because magnesium sulfate can cause fluid retention and swelling, not dehydration.Choice C is wrong because magnesium sulfate can cause drowsiness and lethargy, not insomnia and restlessness.Choice D is wrong because magnesium sulfate can cause decreased blood pressure and heart rate, not inflammation and infection at the infusion site.
Normal ranges for blood pressure are below 140/90 mm Hg, for platelet count are 150,000 to 450,000 per microliter of blood, and for protein in urine are less than 300 milligrams per day.
Correct Answer is C
Explanation
Headache unrelieved by analgesics.This is because headache is a common symptom of HELLP syndrome, a rare pregnancy complication that can cause high blood pressure, seizures, stroke or liver rupture.HELLP syndrome is a type of preeclampsia and has similar symptoms.
Choice A is wrong because breast engorgement is a normal postpartum condition that occurs when the breasts are full of milk and become swollen and tender.
It is not related to HELLP syndrome.
Choice B is wrong because lochia rubra for 3 days postpartum is a normal finding that indicates the shedding of the uterine lining after delivery.
It is not related to HELLP syndrome.
Choice D is wrong because perineal discomfort is a common postpartum discomfort that results from the stretching and tearing of the perineal tissues during vaginal delivery.
It is not related to HELLP syndrome.
Normal ranges for blood pressure are less than 120/80 mmHg, for platelet count are 150,000 to 450,000 per microliter, and for liver enzymes are 7 to 56 units per liter for AST and 0 to 35 units per liter for ALT.
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