A nurse is caring for a client with severe pre-eclampsia who is receiving magnesium sulfate.
Which of the following findings would indicate magnesium toxicity and require immediate intervention?
Urinary output of 25 mL/hour
Respiratory rate of 14 breaths/minute
Deep tendon reflexes 1+
Serum magnesium level of 6 mg/dL
The Correct Answer is A
A. Urinary output of 25 mL/hour. This indicates magnesium toxicity and requires immediate intervention because it means the kidneys are not functioning properly and magnesium is not being excreted. Magnesium toxicity can cause life-threatening complications such as respiratory depression, cardiac arrest, and coma.
B. Respiratory rate of 14 breaths/minute is normal and does not indicate magnesium toxicity. A respiratory rate of less than 12 breaths/minute or more than 20 breaths/minute would be abnormal and require further assessment.
C. Deep tendon reflexes 1+ are normal and do not indicate magnesium toxicity. A loss of deep tendon reflexes or clonus would indicate magnesium toxicity and require immediate intervention.
D. Serum magnesium level of 6 mg/dL is within the therapeutic range for preeclampsia and does not indicate magnesium toxicity.
The therapeutic range for preeclampsia is 4 to 7 mg/dL. A serum magnesium level of more than 8 mg/dL would indicate magnesium toxicity and require immediate intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because HELLP syndrome is a complication of pregnancy that affects the liver and blood clotting.It can cause liver damage, bleeding problems, and high blood pressure.Epigastric pain or right upper quadrant pain is a sign of liver injury or rupture.
Choice B is wrong because blurred vision or flashes of light are symptoms of preeclampsia, not HELLP syndrome.
Preeclampsia is a condition that causes high blood pressure and protein in the urine during pregnancy.It can lead to HELLP syndrome, but not all women with preeclampsia develop HELLP syndrome.
Choice C is wrong because decreased urinary output or oliguria are also symptoms of preeclampsia, not HELLP syndrome.
Oliguria means producing less than 400 mL of urine in 24 hours.It can indicate kidney damage or failure due to high blood pressure or proteinuria.
Choice D is wrong because hyperreflexia or clonus are also symptoms of preeclampsia, not HELLP syndrome.
Hyperreflexia means having exaggerated reflexes, while clonus means having involuntary muscle spasms.
They can indicate nervous system involvement or seizures due to high
Correct Answer is C
Explanation
Magnesium sulfate.Magnesium sulfate is thedrug of choiceto prevent and treat seizures in people with severe preeclampsia and eclampsia.It is an anticonvulsant medication that reduces the risk of eclampsia by 50%.
Choice A is wrong because hydralazine is a blood pressure medication that can lower blood pressure in people with preeclampsia or eclampsia, but it does not prevent seizures.
Choice B is wrong because nifedipine is another blood pressure medication that can lower blood pressure in people with preeclampsia or eclampsia, but it does not prevent seizures.
Choice D is wrong because diazepam is an anticonvulsant medication that was previously used to treat eclamptic seizures, but it has been replaced by magnesium sulfate as the preferred drug due to its better safety and efficacy.Diazepam can also cause sedation and respiratory depression in the mother and the fetus.
Normal ranges for blood pressure are below 140/90 mm Hg, for proteinuria are below 300 mg/24 hours, for platelet count are 150,000 to 450,000 per microliter, for liver enzymes are 7 to 56 units per liter for alanine aminotransferase (ALT) and 10 to 40 units per liter for aspartate aminotransferase (AST), and for magnesium levels are 1.5 to 2.5 mEq/L.
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