Practice Question
A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulphate via continuous IV infusion. Which of the following findings should the nurse report to the provider?
Answer Choices:
Correct Answer:
Absent deep tendon reflexes
Rationale:
🔴 Magnesium sulfate is a central nervous system depressant used to prevent seizures in clients with severe preeclampsia.
🔴 One of the earliest signs of toxicity is the loss of deep tendon reflexes (DTRs), which precedes respiratory depression and cardiac issues.
🔴 Nurses must assess reflexes frequently during infusion to ensure safe serum levels of the drug.
🔴 A respiratory rate of 12–20/min and urinary output >30 mL/hr are considered within acceptable limits, but absent reflexes warrant immediate intervention.
🔴 The nurse should notify the provider and prepare to administer calcium gluconate, the antidote.
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This question is from RN ATI Maternal Newborn Exam 2 which contains 19 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Maternal & Newborn Care
- Answer Choices: 4