# Stage 5 — Take action. Twenty minutes after magnesium sulfate is started, categorize each finding by the concern it most directly supports. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=568580&lang=en > language: en > subject: Pharmacological and Parenteral Therapies > category: PPT ## Question Stage 5 — Take action. Twenty minutes after magnesium sulfate is started, categorize each finding by the concern it most directly supports. **1.** Respiratory rate 10/min Select a category Supports uncontrolled severe preeclampsia Supports magnesium toxicity or accumulation Currently reassuring but not sufficient to stop surveillance **2.** Absent patellar reflexes Select a category Supports uncontrolled severe preeclampsia Supports magnesium toxicity or accumulation Currently reassuring but not sufficient to stop surveillance **3.** Urine output 15 mL in the past hour Select a category Supports uncontrolled severe preeclampsia Supports magnesium toxicity or accumulation Currently reassuring but not sufficient to stop surveillance **4.** Blood pressure 164/110 mm Hg Select a category Supports uncontrolled severe preeclampsia Supports magnesium toxicity or accumulation Currently reassuring but not sufficient to stop surveillance **5.** Persistent severe headache Select a category Supports uncontrolled severe preeclampsia Supports magnesium toxicity or accumulation Currently reassuring but not sufficient to stop surveillance **6.** SpO2 96% with a reassuring fetal tracing Select a category Supports uncontrolled severe preeclampsia Supports magnesium toxicity or accumulation Currently reassuring but not sufficient to stop surveillance ## Explanation Respiratory depression, absent reflexes, and oliguria support magnesium accumulation or toxicity. Persistent severe pressure and headache show uncontrolled severe preeclampsia. Normal oxygen saturation and a now-reassuring fetal tracing do not erase the other urgent findings. ## In-depth explanation Quick answer The respiratory, reflex, and urine findings point to magnesium toxicity, while severe pressure and headache show that preeclampsia remains uncontrolled. Why this is correct Magnesium is cleared through the kidneys, so oliguria can permit accumulation. Respiratory depression and loss of deep-tendon reflexes are toxicity warnings that require stopping the infusion, supporting breathing, notifying the team, and preparing the prescribed antidote while severe hypertension is also treated. Easy analogy or mental picture Use two red folders: one for medication accumulation and one for the disease still progressing. A reassuring oxygen value or fetal tracing belongs in neither red folder but cannot close them. Memory hook Low urine, lost reflexes, low respirations: stop magnesium and escalate. NCLEX decision rule When magnesium is infusing, check respirations, reflexes, and urine output; if toxicity cues appear, stop exposure and support ABCs before resuming any infusion. Why the other choices are wrong Normal oxygen saturation and a temporarily reassuring fetal tracing do not make respiratory depression, oliguria, severe hypertension, or neurologic symptoms safe. References 1ACOG Practice Bulletin 222: Gestational Hypertension and PreeclampsiaUrgent blood-pressure control, magnesium monitoring, and severe-feature management; reaffirmed 2026 ## Clinical scenario Case update New data — RR is 10/min, patellar reflexes are absent, urine output was 15 mL in the past hour, BP is 164/110 mm Hg, and severe headache persists. SpO2 is 96%, and the fetal tracing now has moderate variability without decelerations. ## Related questions - [A nurse is programming a high-alert IV medication on a smart infusion pump. 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