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","B"]
Explanation
Choice A rationale
Postpartum hemorrhage (PPH) is a significant risk for this client due to several factors including a macrosomic neonate (birth weight >4000 grams), which causes overdistention of the uterus. Uterine overdistention stretches the muscle fibers, impairing the uterus's ability to contract effectively (uterine atony) after birth, which is the leading cause of PPH (normal blood loss range: ≤ 500 mL for vaginal birth).
Choice B rationale
A rapid labor (4 hours) and the birth of a macrosomic neonate (4200 grams) increase the risk of vaginal lacerations and tears to the soft tissues of the birth canal. The rapid passage of a large fetal head/shoulder diameter can cause uncontrolled and forceful tearing, often extending into the perineal musculature, leading to potential complications and excessive blood loss.
Choice C rationale
Uterine inversion, the collapse of the fundus into the endometrial cavity, is a rare but severe complication. While associated with factors like aggressive cord traction or fundal pressure, this client's history of macrosomia and rapid labor primarily increases the risk for uterine atony and lacerations, making inversion a much less likely, though possible, complication.
Choice D rationale
Postpartum hypertension (PHTN) is generally related to a history of pre-eclampsia or chronic hypertension. This client's presentation of macrosomia and rapid labor primarily increases the risk for mechanical/anatomical complications like uterine atony and lacerations rather than a primary vasospastic or systemic vascular disorder such as PHTN.
Correct Answer is ["B","C"]
Explanation
Choice A rationale
An analgesic like meperidine (Demerol) or butorphanol (Stadol) is typically used for pain management during labor but is not a primary therapeutic agent for addressing preterm labor (PTL) itself. While pain relief may be important, the essential interventions for PTL at 31 weeks gestation focus on stopping contractions and preparing the fetus for potential early delivery.
Choice B rationale
Corticosteroids, such as betamethasone or dexamethasone, are administered to the client in PTL between 24 and 34 weeks gestation. These medications promote fetal lung maturity by stimulating the production and release of surfactant and reduce the incidence and severity of respiratory distress syndrome (RDS), intraventricular hemorrhage, and neonatal mortality.
Choice C rationale
A tocolytic is a class of drugs used to suppress uterine contractions in an attempt to delay delivery, giving time for corticosteroids to take effect and for in-utero transfer if necessary. Examples include magnesium sulfate, nifedipine, or terbutaline, aiming to prolong the pregnancy by at least 48 hours to maximize steroid benefit.
Choice D rationale
An oxytocic medication, such as oxytocin (Pitocin) or methylergonovine, stimulates uterine contractions and is used for labor induction/augmentation or to prevent/treat postpartum hemorrhage. Providing an oxytocic to a client in preterm labor is contraindicated as it would accelerate delivery, which is the exact outcome one is attempting to prevent.
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