Deep tendon reflexes are important to monitor because they indicate the level of neuromuscular irritability caused by magnesium sulfate therapy.Magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia.A healthcare provider will give the medication intravenously.If the deep tendon reflexes are absent or diminished, it may indicate magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.

Other statement options:

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A. Blood pressure: Blood pressure is a major sign of preeclampsia, but it is not the most important assessment to monitor when receiving magnesium sulfate therapy.Blood pressure may be controlled by other antihypertensive medications.

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C. Fetal heart rate: Fetal heart rate is important to monitor for fetal well-being, but it is not directly affected by magnesium sulfate therapy.Fetal heart rate may be monitored by nonstress test or biophysical profile.

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D. Urine output: Urine output is important to monitor for kidney function, but it is not the most important assessment to monitor when receiving magnesium sulfate therapy.Urine output may be measured by urine analysis or 24-hour urine sample.

Normal ranges:

• Blood pressure: less than 140/90 mm Hg

• Deep tendon reflexes: 2+ (normal) or 3+ (brisk) on a scale of 0 to 4

• Fetal heart rate: 110 to 160 beats per minute

• Urine output: at least 30 mL per hour

Turn the client to the side.This is because turning the client to the side will prevent aspiration and maintain a patent airway, which is the priority intervention for a client who has a seizure.

Some possible explanations for the other choices are:

• Choice B. Administer oxygen via face mask.

This is not the first action because oxygen administration alone will not prevent aspiration or ensure a patent airway.Oxygen may be given after turning the client to the side and assessing the respiratory status.

• Choice C. Give additional magnesium sulfate.

This is not the first action because magnesium sulfate is used to prevent seizures in clients with eclampsia, not to treat them once they occur.Magnesium sulfate may be given after stabilizing the client and checking the serum magnesium level, which should be between 4 to 7 mg/dL (3.3 to 5.8 mEq/L) for therapeutic effect.

• Choice D. Document the duration and characteristics of the seizure.

This is not the first action because documentation is important but not urgent in this situation.The nurse should document the seizure after providing immediate care and notifying the provider.

Hydralazine is a medication that lowers blood pressure by relaxing the blood vessels.It is used to treat hypertension in pre-eclampsia, a condition that causes high blood pressure and proteinuria in pregnant women.Hydralazine can cause side effects such as palpitations, tachycardia, chest pain, and headache.

Therefore, the nurse should monitor the heart rate before and after giving the medication to assess the effectiveness and safety of the treatment.

Choice B. Respiratory rate is wrong because hydralazine does not affect the respiratory system directly.However, if the blood pressure is too low, it can cause difficulty breathing or shortness of breath.

This is a sign of hypotension or shock and requires immediate medical attention.

Choice C. Temperature is wrong because hydralazine does not cause fever or affect the body temperature.However, some people may experience a feeling of warmth or flushing after taking hydralazine.

This is a normal reaction and does not indicate a problem.

Choice D. Oxygen saturation is wrong because hydralazine does not affect the oxygen level in the blood.

However, if the blood pressure is too low, it can cause decreased blood flow to the vital organs, which can lead to hyp

D-dimer level of 0.8 mcg/mL.

D-dimer is a protein fragment that is produced when a blood clot dissolves.A high level of D-dimer indicates a risk for disseminated intravascular coagulation (DIC), a condition in which blood clots form throughout the body and block blood flow to vital organs.

Choice A is wrong because platelet count of 150,000/mm3 is within the normal range for adults, which is between 150,000 and 450,000 platelets/mcL.Platelet count may decrease in DIC due to excessive clotting and consumption of platelets.

Choice B is wrong because fibrinogen level of 300 mg/dL is within the normal range for adults, which is between 200 and 400 mg/dL.

Fibrinogen is a protein that helps blood clotting.Fibrinogen level may increase in DIC due to inflammation and tissue injury.

Choice C is wrong because prothrombin time of 15 seconds is within the normal range for adults, which is between 11 and 13.5 seconds.

Prothrombin time measures how long it takes for blood to clot.Prothrombin time may increase in DIC due to depletion of clotting factors.

“I should not worry if I do not feel my baby move as much as before.” This statement indicates a need for further teaching because decreased fetal movement is a sign of fetal distress and should be reported to the nurse immediately.

Magnesium toxicity can affect the fetal central nervous system and cause hypotonia and reduced activity.

Choice A is wrong because difficulty breathing is a sign of magnesium toxicity and should be reported to the nurse.

Magnesium can depress the respiratory system and cause respiratory failure.

Choice B is wrong because warmth and flushing are common side effects of magnesium infusion and do not indicate toxicity.

They are caused by the vasodilatory effect of magnesium on the blood vessels.

Choice C is wrong because blurred vision and headache are signs of severe pre-eclampsia and should be reported to the nurse.

They indicate increased blood pressure and possible cerebral edema.