A client at 34 weeks has severe preeclampsia with blood pressure 170/110 mm Hg, 4+ reflexes, and a severe headache. Magnesium sulfate and antihypertensive therapy are prescribed. For each group, select all responses that apply.

Severe preeclampsia requires seizure prophylaxis and close maternal-fetal surveillance. Administer prescribed magnesium sulfate and use continuous fetal monitoring. During the infusion, assess respiratory rate, level of consciousness, reflexes, and hourly urine output because reduced renal clearance increases magnesium toxicity risk. Ambulation and excess oral fluids are unsafe, blood pressure requires more frequent assessment than every four hours, and magnesium toxicity surveillance cannot be deferred until after delivery.

Use only the findings, timing, and orders stated in the scenario.

Apply the requested nursing decision to this client rather than relying on a broad disease label.

The remaining responses are contradicted by the scenario, mistimed, outside scope, or unsafe.

Address immediate threats first and reassess after intervention.

Choose only actions supported at this exact point in care.

• Magnesium sulfate — Used for seizure prophylaxis in severe preeclampsia; requires close monitoring for toxicity.
• Deep tendon reflexes — Assessed to detect hyperreflexia (preeclampsia) or hyporeflexia (magnesium toxicity).
• Continuous fetal monitoring — Essential to evaluate fetal status in severe preeclampsia due to uteroplacental insufficiency risk.