A nurse is caring for a client who is receiving intravenous magnesium sulfate for preeclampsia.
Which assessment finding would alert the nurse to suspect magnesium toxicity?
Rapid pulse.
Tingling in toes.
Cool skin temperature.
Absent deep tendon reflexes.
The Correct Answer is D
Choice A rationale
A rapid pulse is not typically associated with magnesium toxicity. Magnesium toxicity more commonly affects the nervous and muscular systems.
Choice B rationale
Tingling in toes can be a sign of early magnesium sulfate effects but not necessarily toxicity. It may indicate that the medication is starting to affect the nervous system.
Choice C rationale
Cool skin temperature is not a common sign of magnesium toxicity. Symptoms of magnesium toxicity are more related to neuromuscular and respiratory function.
Choice D rationale
Absent deep tendon reflexes are a key indicator of magnesium toxicity. This finding suggests that magnesium levels are high enough to depress neuromuscular function, requiring immediate medical intervention. .
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View Related questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Recurrent variable decelerations can indicate umbilical cord compression. Notifying the provider ensures immediate intervention if necessary to address potential fetal distress and to
monitor labor progression.
Choice B rationale
Ambulation is not recommended with recurrent variable decelerations. It might increase the risk of cord prolapse or other complications, further compromising fetal wellbeing.
Choice C rationale
Repositioning to the left lateral position helps improve uteroplacental blood flow and reduce cord compression, addressing the decelerations and promoting fetal oxygenation.
Choice D rationale
Performing a sterile vaginal exam can help identify any immediate issues like cord prolapse or rapid cervical changes that could impact labor management and fetal wellbeing.
Choice E rationale
Providing an IV fluid bolus can improve maternal hydration and placental perfusion, potentially alleviating the cause of variable decelerations by increasing blood flow and reducing cord
compression effects. .
Correct Answer is B
Explanation
Choice A rationale
Hyperbilirubinemia presents with jaundice (yellowing of the skin and eyes) and is caused by excess bilirubin in the blood. It doesn't typically involve a high-pitched cry, increased
muscle tone, or projectile vomiting.
Choice B rationale
Neonatal abstinence syndrome occurs in newborns exposed to addictive opiate drugs while in the mother’s womb. Symptoms include high-pitched crying, increased muscle tone,
yawning, poor feeding with vomiting, and tachypnea due to drug withdrawal.
Choice C rationale
Respiratory distress syndrome is primarily characterized by breathing difficulties, including rapid, shallow breathing and a grunting sound. Symptoms do not typically include high-
pitched cry or projectile vomiting.
Choice D rationale
Necrotizing enterocolitis involves severe inflammation and necrosis of the intestines. Symptoms include abdominal distension, vomiting bile, bloody stools, and apnea but not a high-
pitched cry or increased muscle tone.