More Questions on this Topic

More Questions on this Topic ( 35 Questions)

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia.

Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.



Correct Answer: ["A","B","C","E"]

The correct answer is choice A, B, C and E. The nurse should monitor for magnesium toxicity by assessing the deep tendon reflexes, respiratory rate, urine output and serum magnesium level of the client who has severe preeclampsia and is receiving magnesium sulfate IV. Magnesium toxicity can cause life-threatening complications such as hypotension, areflexia (loss of DTRs), respiratory depression, respiratory arrest, oliguria, shortness of breath, chest pains, slurred speech and cardiac arrest. The nurse should also have calcium chloride ready as an antidote for magnesium toxicity.

Choice D is wrong because fetal heart rate is not a direct indicator of magnesium toxicity. However, the nurse should still monitor the fetal heart rate and uterine activity per the Electronic Fetal Monitoring (EFM) Guideline.

Normal ranges for the assessments are:

• Deep tendon reflexes: 1+ to 4+ (normal to hyperactive)

• Respiratory rate: 12 to 20 breaths per minute

• Urine output: at least 30 mL per hour

• Serum magnesium level: 4 to 7 mg/dL (therapeutic range for preeclampsia)




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