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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?

A.

Rapid pulse.

B.

Tingling in toes.

C.

Cool skin temperature.

D.

Absent deep tendon reflexes.

Answer and Explanation

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

Explanation

Choice A rationale

Pelvic pain and fatigue can be indicators of endometritis, an infection of the uterine lining. It often manifests with pain, fever, and general malaise, and requires further evaluation and intervention.

Choice B rationale

Light amount of dark red lochia with a bloody odor is a normal postpartum finding. Lochia progresses through different stages, and dark red lochia, which occurs in the later stages, typically has a bloody odor.

Choice C rationale

Hematuria, or the presence of blood in the urine, is not a typical symptom of endometritis. It may indicate a urinary tract infection or other renal issues instead.

Choice D rationale

A localized area of breast tenderness may indicate mastitis, an infection of the breast tissue. It is not related to endometritis but requires attention and treatment.

Correct Answer is C

Explanation

Choice A rationale

A maternal blood pressure of 128/88 mm Hg is within normal limits for a pregnant woman. Regular monitoring is necessary, but no immediate follow-up is required unless symptoms

of preeclampsia appear.

Choice B rationale

A fetal heart rate baseline of 115 bpm is within the normal range (110-160 bpm). This does not require immediate follow-up and is a reassuring sign of fetal well-being.

Choice C rationale

A maternal heart rate of 128 bpm is elevated (tachycardia) and may indicate distress, infection, dehydration, or other underlying conditions. This requires immediate follow-up to identify and address the cause.

Choice D rationale

A maternal respiratory rate of 18 breaths per minute is within the normal range (12-20 breaths per minute) and does not require immediate follow-up.

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