A client with severe preeclampsia is receiving magnesium sulfate. For each assessment cluster, identify the safest nursing response.
Matrix
Choose your responses, then check the answer.
Explanation
Adequate respirations, present reflexes, and urine output above the ordered safety threshold support continuing therapy with routine monitoring. Falling urine output, increasing drowsiness, or diminished reflexes can indicate accumulation and require pausing the infusion and urgent review before severe toxicity develops. Absent reflexes with respiratory depression or unresponsiveness requires stopping magnesium, supporting ventilation, escalating immediately, and preparing an injectable calcium salt as prescribed. A serum level may support the diagnosis, but severe bedside signs require action before a laboratory result returns.
Correct Answer Continue for the 2 stable clusters, pause and notify for the 2 early-accumulation clusters, and initiate the severe-toxicity response for the 2 clusters with respiratory or neurologic compromise.
Why It Fits Magnesium is cleared by the kidneys and depresses neuromuscular and respiratory function as it accumulates. Trend and cue combinations determine the response.
Clinical Picture Urine output and reflex changes can warn before profound respiratory depression. Once breathing or consciousness is compromised, airway support and calcium preparation take priority.
Memory Link Flow, reflex, breath: worsening flow prompts review; lost reflex plus slow breath prompts rescue.
NCLEX Rule Interpret the cluster and act at the highest level of current instability; do not wait for a routine serum level when severe toxicity signs are present.
Why the Alternatives Fail Continuing through declining renal clearance risks further accumulation. Giving calcium for every mild change is excessive, while mere observation is unsafe when reflexes and breathing are severely depressed.
Sources
1DailyMed: Magnesium Sulfate in Dextrose Injection
22026 NCLEX-RN Test Plan
The infusion has been running for 6 hours. The nurse interprets respirations, deep tendon reflexes, urine output, level of consciousness, and seizure control together rather than reacting to one isolated value.
Magnesium Sulfate — Medication used to prevent or treat eclamptic seizures.
Deep Tendon Reflex — A neurologic response monitored during magnesium therapy.
Respiratory Depression — Slow or inadequate breathing.