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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the rationale for using this medication in a client with pre-eclampsia who has a blood pressure of 180/110 mmHg.High blood pressure in pre-eclampsia can cause damage to the kidneys, liver, brain, and other organs, and can also increase the risk of complications for the baby.
Therefore, lowering blood pressure with hydralazine can help prevent or reduce these adverse outcomes.
Choice A is wrong because hydralazine does not reduce cerebral edema or prevent seizures.These are symptoms of eclampsia, a more severe form of pre-eclampsia that requires different treatment.
Choice B is wrong because hydralazine does not increase uteroplacental perfusion or fetal oxygenation.These are affected by other factors such as the placental function, maternal position, and fetal well-being.
Choice C is wrong because hydralazine does not decrease proteinuria or prevent renal damage.
Proteinuria is a sign of kidney impairment that occurs in pre-eclampsia, but it is not directly affected by hydralazine.Renal damage can be prevented by controlling blood pressure and avoiding nephrotoxic drugs.
Correct Answer is ["C","D"]
Explanation
The correct answer is choice C and D.Epigastric pain and decreased fetal movement are signs of severe pre-eclampsia that indicate damage to the liver and placenta respectively.These symptoms should be reported to the health care provider immediately as they may lead to serious complications such as eclampsia, HELLP syndrome, placental abruption or fetal growth restriction.
Choice A is wrong because sudden weight gain is a common symptom of mild pre-eclampsia that does not necessarily require immediate attention.However, it should be monitored regularly along with blood pressure and urine protein levels.
Choice B is wrong because swelling of the face and hands is also a common symptom of mild pre-eclampsia that does not indicate severe organ damage.It may be caused by fluid retention or edema.
Choice E is wrong because vaginal bleeding is not a typical symptom of pre-eclampsia.It may be a sign of other pregnancy complications such as placenta previa, placental abruption or cervical infection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today