# 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.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=620045&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

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.

Immediate actions

Initiate continuous fetal monitoring

Administer the prescribed magnesium sulfate loading dose

Encourage hallway ambulation to reduce blood pressure

Increase oral fluids without considering the prescribed fluid plan

Ongoing monitoring

Assess respiratory rate, level of consciousness, and deep tendon reflexes at the prescribed intervals

Measure urine output hourly

Measure blood pressure only every 4 hours

Defer magnesium-toxicity assessment until after delivery

## Explanation

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.

## In-depth explanation

Quick answer
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.
Key cues
Use only the findings, timing, and orders stated in the scenario.
Clinical reasoning
Apply the requested nursing decision to this client rather than relying on a broad disease label.
Why the alternatives do not fit
The remaining responses are contradicted by the scenario, mistimed, outside scope, or unsafe.
Priority and safety
Address immediate threats first and reassess after intervention.
Takeaway
Choose only actions supported at this exact point in care.
**Sources**
- Open RN Nursing Skills 2e

## Clinical scenario

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.

## Key concepts

- **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.

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