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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

Blood pressure should be addressed first due to the client’s elevated BP (144/92 mmHg), which is a potential sign of complications such as preeclampsia.

Choice B rationale

Pulse of 99 bpm is slightly elevated but not immediately concerning compared to the high BP.

Choice C rationale

Respirations are within normal range (17/min) and do not require immediate intervention.

Choice D rationale

Temperature of 100.4°F (38.0°C) is slightly elevated but not as critical as the high BP.

Correct Answer is B

Explanation

Choice A rationale

Umbilical cord compression typically results in variable decelerations in the fetal heart rate, not moderate variability or regular accelerations. It can lead to changes in fetal heart rate

patterns, but not regular mild contractions.

Choice B rationale

Dysfunctional labor refers to an abnormal labor pattern, including irregular uterine contractions. The described symptoms fit this condition, as they can cause mild pain and be

managed by ambulation, showers, and rest.

Choice C rationale

Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, leading to fever, uterine tenderness, and foul-smelling amniotic fluid, not mild contractions and moderate

variability in FHR.

Choice D rationale

Iron deficiency anemia in pregnancy can cause fatigue, pallor, and shortness of breath but does not affect uterine contractions or fetal heart rate.

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