# A client with severe preeclampsia is receiving magnesium sulfate. For each assessment cluster, identify the safest nursing response. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=395585&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## Question A client with severe preeclampsia is receiving magnesium sulfate. For each assessment cluster, identify the safest nursing response. | | Continue infusion and routine monitoring | Pause infusion and notify the prescribing team | Stop infusion, support breathing, and prepare calcium as ordered | | --- | --- | --- | --- | | Awake and oriented; respirations 16/min; patellar reflexes 2+; urine output 45 mL/hr; no seizure activity | | | | | Mild flushing; respirations 18/min; patellar reflexes 2+; urine output 50 mL/hr; fetal and maternal status otherwise stable | | | | | Urine output 20 mL/hr for 2 hours; respirations 14/min; patellar reflexes decreased to 1+ | | | | | Increasing drowsiness; respirations 12/min; patellar reflexes newly 1+; urine output falling from 40 to 25 mL/hr | | | | | Respirations 8/min with absent patellar reflexes and difficulty staying awake | | | | | Unresponsive with shallow respirations 7/min and hypotension while magnesium is infusing | | | | ## 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. ## In-depth explanation 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 ## Clinical scenario 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. ## Key concepts - **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. ## Related questions - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=en) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=en) - [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=en) - [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. 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Always follow current clinical guidelines and your institution’s protocols._