A client with severe preeclampsia is receiving an IV magnesium sulfate infusion. For each finding or action, select the best classification.
Matrix
Choose your responses, then check the answer.
Explanation
Respiratory depression and absent patellar reflexes suggest magnesium toxicity. Adequate urine output and immediate calcium availability support safe therapy. If toxicity is suspected, stop the infusion, escalate, support ventilation, and administer prescribed IV calcium; do not wait for a serum level before acting.
Quick answer Recognize respiratory depression and absent patellar reflexes as magnesium-toxicity cues. Stop the infusion, call for urgent help, support breathing, and prepare prescribed IV calcium.
Why this is correct Magnesium depresses neuromuscular transmission. Loss of the patellar reflex can precede severe respiratory paralysis, and reduced urine output increases accumulation because magnesium is cleared by the kidneys.
Easy analogy or mental picture Reflexes and respirations are bedside warning lights; urine output shows whether the body can clear the medication.
Memory hook Reflexes fade, breathing slows: stop magnesium and reach for calcium.
NCLEX decision rule Monitor respiratory rate, patellar reflexes, and urine output during the infusion. Keep calcium gluconate and airway support available. Clinical toxicity requires immediate action; a laboratory magnesium result can support management but must not delay stabilization.
Why the other choices are wrong Continuing the infusion or waiting for additional findings can permit progression to paralysis and circulatory collapse. A normal urine output does not cancel new respiratory depression or absent reflexes.
Source
1ACOG Practice Bulletin: Gestational Hypertension and Preeclampsia
2DailyMed: Magnesium Sulfate Injection Prescribing Information
32026 NCLEX-RN Test Plan
The nurse monitors respiratory status, patellar reflexes, blood pressure, urine output, and neurologic findings throughout therapy. Calcium gluconate and emergency airway equipment are immediately available according to protocol.
Hypermagnesemia — An abnormally elevated serum magnesium concentration that can depress reflexes, respiration, cardiac conduction, and circulation.
Patellar reflex — The knee-jerk deep tendon reflex used as a bedside indicator of neuromuscular function during magnesium therapy.
Calcium gluconate — An IV calcium salt used as an antagonist to counter clinically significant magnesium toxicity.