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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 D

Explanation

Choice A rationale

Breast tenderness is considered a presumptive sign of pregnancy, as it can result from hormonal changes, but it is not definitive enough to confirm pregnancy.

Choice B rationale

Fetal heart tones detected by ultrasound are a positive sign of pregnancy. However, it is not a probable sign as it is definitive evidence of an existing pregnancy.

Choice C rationale

Fetal movement, often felt later in pregnancy, is a positive sign. It indicates an existing pregnancy but is not used to initially diagnose pregnancy.

Choice D rationale

A positive urine pregnancy test is a probable sign of pregnancy. It detects the presence of hCG (human chorionic gonadotropin), a hormone produced during pregnancy, and is a widely used indicator of probable pregnancy. .

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.

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