# A nurse is caring for a 28-year-old primigravida at 36 weeks' gestation who is receiving intravenous magnesium sulfate for severe preeclampsia. Which finding requires the nurse to immediately discontinue the magnesium infusion?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=505802&lang=en  
> language: en  
> subject: Pharmacological and Parenteral Therapies  
> category: PPT

## Question

A nurse is caring for a 28-year-old primigravida at 36 weeks' gestation who is receiving intravenous magnesium sulfate for severe preeclampsia. Which finding requires the nurse to immediately discontinue the magnesium infusion?

## Option

1. Patellar reflexes 2+ and respiratory rate 16/min
2. Urine output 40 mL/hr and blood pressure 150/95 mm Hg
3. Patellar reflexes absent and respiratory rate 10/min **✔ Correct answer**
4. Deep tendon reflexes 3+ and clonus present

**Correct answer: 3**

## Explanation

Absent patellar reflexes and a respiratory rate of 10/min indicate magnesium sulfate toxicity, which can progress to respiratory arrest. The nurse must immediately stop the infusion, provide respiratory support, notify the provider, and prepare to administer calcium gluconate as prescribed. Patellar reflexes 2+ and respiratory rate 16/min are normal findings. Urine output of 40 mL/hr is adequate, and a blood pressure of 150/95 mm Hg, while elevated, does not indicate toxicity. Deep tendon reflexes 3+ and clonus suggest central nervous system irritability, not magnesium toxicity.

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