# A 31-year-old client, gravida 1, at 35 weeks of gestation with preeclampsia with severe features has received magnesium sulfate at 2 g/hour for 10 hours after a 4 g loading dose. No seizure activity has been observed. Current findings: respiratory rate 9/min, oxygen saturation 91% on room air, blood pressure 150/96 mm Hg, patellar reflexes absent, and urine output 18 mL/hour for the past 2 hours. The client is difficult to arouse but moves all extremities equally, and pupils are 3 mm, equal, and reactive. Laboratory results: serum creatinine 1.4 mg/dL (0.8 mg/dL on admission), platelets 186,000/mm3, and AST 28 units/L. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617411&lang=en > language: en > subject: Lifestyle Choices > category: HPM ## Question A 31-year-old client, gravida 1, at 35 weeks of gestation with preeclampsia with severe features has received magnesium sulfate at 2 g/hour for 10 hours after a 4 g loading dose. No seizure activity has been observed. Current findings: respiratory rate 9/min, oxygen saturation 91% on room air, blood pressure 150/96 mm Hg, patellar reflexes absent, and urine output 18 mL/hour for the past 2 hours. The client is difficult to arouse but moves all extremities equally, and pupils are 3 mm, equal, and reactive. Laboratory results: serum creatinine 1.4 mg/dL (0.8 mg/dL on admission), platelets 186,000/mm3, and AST 28 units/L. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition Select 1 HELLP syndrome Magnesium sulfate toxicity Postictal state after eclampsia Intracranial hemorrhage Actions to take Select 2 Stop the magnesium sulfate infusion Administer prescribed IV labetalol Give a 500 mL IV fluid bolus for the low urine output Reduce the infusion to 1 g/hour Administer prescribed IV calcium gluconate Parameters to monitor Select 2 Platelet count Pupil size and reactivity Serum magnesium level Urine protein-to-creatinine ratio Respiratory rate ## Explanation Respiratory depression, absent reflexes, and decreased arousal during magnesium infusion, with oliguria and rising creatinine reducing magnesium excretion, indicate magnesium toxicity. The nurse stops the infusion and gives prescribed IV calcium gluconate as the antagonist. Respiratory rate and serum magnesium show whether toxicity is reversing. Normal platelets and AST, no witnessed seizure, and equal pupils argue against the differentials. ## In-depth explanation Quick answer Magnesium sulfate toxicity; stop the infusion, give prescribed IV calcium gluconate, and monitor respiratory rate and serum magnesium level. Why this is correct Magnesium is excreted by the kidneys, and this client's urine output has fallen with a creatinine rising from 0.8 to 1.4 mg/dL, so magnesium accumulates. Loss of reflexes comes first, then respiratory depression and reduced consciousness. Stopping the source and giving calcium to antagonize magnesium at the neuromuscular junction are the immediate treatments. Easy analogy or mental picture Picture a bathtub with the tap running (the infusion) and the drain partly blocked (the kidneys): the water rises until it spills over. Turn off the tap first. Memory hook Reflexes gone, breaths under 12, urine under 30 = shut off magnesium, grab calcium. NCLEX decision rule During a high-alert infusion, new depression of reflexes, breathing, or consciousness means stop the drug and give its antidote before looking for other causes. Why the other choices are wrong HELLP syndrome would show low platelets and elevated liver enzymes, which are normal here, so trending platelets does not track this problem. A postictal state requires a seizure, and none occurred. Intracranial hemorrhage would produce focal deficits or unequal pupils, so pupil checks are less specific. Labetalol is for severe-range pressure of 160/110 mm Hg or higher, which this client does not have. A fluid bolus risks pulmonary edema in preeclampsia and does not treat toxicity, and reducing the rate continues giving a drug the client cannot clear. The protein-to-creatinine ratio describes preeclampsia severity, not magnesium levels. References 1ACOG Practice Bulletin 222 — Gestational Hypertension and PreeclampsiaMagnesium sulfate requires monitoring of reflexes, respirations, and urine output; renal impairment increases toxicity risk. 2MedlinePlus — PreeclampsiaDescribes preeclampsia with severe features and its treatment with magnesium sulfate. ## Clinical scenario Scenario A client with preeclampsia receiving magnesium sulfate has respiratory rate 9/min, absent reflexes, oliguria with rising creatinine, and decreased arousal, with no seizure, normal platelets and AST, and equal pupils. ## Key concepts - **Deep tendon reflexes** — Stretch reflexes such as the patellar reflex; loss is an early sign of magnesium toxicity. - **Calcium gluconate** — The antagonist for magnesium toxicity, given IV to reverse neuromuscular and respiratory depression. - **HELLP syndrome** — Hemolysis, elevated liver enzymes, and low platelets, a severe form of preeclampsia. ## Related questions - [A client who smokes says, “I know smoking worsens my breathing, and part of me wants to qu…](https://mymerci.kr/pages/nclex_q.php?qn_id=393389&lang=en) - [A pregnant client at 34 weeks gestation reports a severe headache and blurred vision. 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