A pregnant client is receiving magnesium sulfate to prevent eclampsia via a continuous intravenous infusion. Hourly assessments are recorded.
Which assessment findings lead the nurse to stop the infusion immediately? Select all that apply.
Client is alert and oriented × 4.
Absent deep tendon reflexes (DTR).
Serum magnesium value of 6 mg/dL.
Urine output of 10 mL/hr.
Glasgow Coma Scale (GCS) of 10.
Respiratory rate of 10 breaths per minute.
Correct Answer : B,D,F
Choice A rationale
Magnesium sulfate is a central nervous system depressant used to prevent seizures in preeclampsia. Being alert and oriented × 4 is a normal finding and indicates the drug is working at a therapeutic level without causing excessive CNS depression. Normal therapeutic serum magnesium is typically 4-7 mg/dL; this assessment finding indicates appropriate mentation.
Choice B rationale
Absent deep tendon reflexes (DTRs) indicate a loss of reflex excitability due to excessive neuromuscular blockade from hypermagnesemia, representing a major sign of magnesium toxicity. This finding suggests a dangerously high serum magnesium level (>8 mg/dL) and indicates immediate intervention is required to prevent profound respiratory depression and cardiac arrest.
Choice C rationale
A serum magnesium value of 6 mg/dL is within the normal therapeutic range of 4-7 mg/dL for preeclampsia management. This level is effective for seizure prophylaxis without typically causing severe signs of toxicity like respiratory depression or absent reflexes. Therefore, a level of 6 mg/dL does not warrant immediate discontinuation of the infusion.
Choice D rationale
A urine output of 10 mL/hr is significantly below the acceptable minimum of 30 mL/hr (or 100 mL/4 hours) for a client receiving magnesium sulfate. Magnesium is primarily excreted by the kidneys, and oliguria leads to drug accumulation, rapidly increasing the risk of magnesium toxicity. Decreased urine output requires immediate cessation of the infusion and potentially administration of an antidote.
Choice E rationale
A Glasgow Coma Scale (GCS) of 10 indicates a moderate neurological impairment, but it is not specific to magnesium toxicity. While a score below 8 would indicate severe CNS depression requiring immediate intubation, a score of 10 alone, without corroborating signs like absent DTRs or respiratory depression, does not immediately necessitate stopping the infusion, as it could relate to the underlying disease.
Choice F rationale
A respiratory rate of 10 breaths per minute is considered bradypnea and is a critical sign of impending respiratory depression, a life-threatening complication of severe magnesium toxicity. Magnesium depresses the respiratory center and paralyzes respiratory muscles at very high levels (>12 mg/dL). Infusion must be stopped immediately, and the antidote (calcium gluconate) must be prepared.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A second-degree perineal laceration involves the vaginal mucosa, perineal skin, and the perineal muscles, but not the anal sphincter. The proximity of the repair to the urethra and the potential for perineal edema and pain can inhibit the voiding reflex and cause urethral spasm, leading to temporary difficulty in spontaneously emptying the bladder post-delivery.
Choice B rationale
The onset of milk production (lactogenesis II) is primarily controlled by the rapid drop in progesterone levels following the expulsion of the placenta and subsequent increase in prolactin release. A second-degree perineal laceration and repair, which is a localized soft tissue injury, has no direct physiological impact on the endocrine cascade responsible for initiating lactation.
Choice C rationale
Maladaptive bonding is a complex psychological issue influenced by factors like maternal mental health, pain, fatigue, and social support. While a painful laceration can contribute to discomfort and stress, a second-degree tear itself is a physical injury and does not directly cause an abnormal bonding process, which is a behavioral and emotional phenomenon.
Choice D rationale
Posterior vaginal varicosities (enlarged veins) are caused by the increased venous pressure and blood volume associated with pregnancy, and potential pressure from the descending fetal head during labor. A second-degree perineal laceration and its repair are the result of the birthing process and do not cause pre-existing vascular conditions like varicosities.
Correct Answer is D
Explanation
Choice A rationale
Placental abruption is the premature detachment of the normally implanted placenta from the uterine wall. The client's placenta is low-implanted, suggesting a placenta previa risk, not abruption. While the small for gestational age (SGA) fetus is associated with placental insufficiency, abruption is typically characterized by acute vaginal bleeding and pain, not exclusively by a low-implanted placenta on ultrasound.
Choice B rationale
Placenta accreta is an abnormal adherence of the placenta to the uterine wall, invading the myometrium. It is a major risk in clients with a history of previous cesarean births or uterine surgery. A low-implanted placenta (previa) on its own, without a history of uterine scarring, is not the primary indicator for accreta planning, which is focused on hemorrhage risk at delivery.
Choice C rationale
Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of gestation. While a small for gestational age (SGA) fetus and placental issues can increase the risk of preterm labor, the specific finding of a low-implanted placenta on a 28-week ultrasound points more directly to the risk of placenta previa, which is the priority teaching topic.
Choice D rationale
Placenta previa is the implantation of the placenta over or near the internal cervical os. A low-implanted placenta revealed at 28 weeks' gestation is a strong indicator of an increased risk for previa as the pregnancy progresses. The associated fetal growth restriction (SGA) is often related to the placenta's suboptimal location and functionality, requiring teaching on bleeding precautions and warning signs.
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