RN Nursing · High-Risk Pregnancy — Hypertensive Disorders · Practice question
A nurse is assessing a client who is receiving IV magnesium sulfate for treatment of preeclampsia. Which of the following findings should the nurse report?
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24 hr urine output 960 mL
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Blood pressure 122/88 mm Hg
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✓
1 + deep tendon reflexes
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Pupils equal, round, react to light, accommodation
Answer & explanation
Correct: 1 + deep tendon reflexes
Magnesium sulfate is used in preeclampsia to prevent seizures (eclampsia), and magnesium toxicity is a serious, potentially fatal complication. One of the earliest signs of magnesium toxicity is the loss of deep tendon reflexes (DTRs). Normal DTR response is graded 2+ (normal); a finding of 1+ indicates hypoactivity, suggesting the magnesium level is approaching the toxic range. If DTRs are absent (0+), this is a more critical finding indicating significant toxicity requiring immediate intervention. The therapeutic range for magnesium sulfate in preeclampsia is 4–7 mEq/L; toxicity occurs progressively with loss of patellar reflexes typically at 7–10 mEq/L, respiratory depression at 10–13 mEq/L, and cardiac arrest above 15 mEq/L. A 24-hour urine output of 960 mL is below the threshold of concern (urine output should be at least 25–30 mL/hr, or roughly 600–720 mL per 24 hours), but 960 mL over 24 hours is adequate. Blood pressure of 122/88 mmHg remains slightly elevated diastolically but is improved. Pupils equal and reactive are a normal, reassuring neurological finding. The 1+ DTR finding is the one that requires prompt reporting as it signals early magnesium toxicity.
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