Final answer:
The nurse should withhold magnesium sulfate and notify the healthcare provider if the client exhibits the absence of deep tendon reflexes, as this is a sign of magnesium toxicity.
Step-by-step explanation:
When caring for a client receiving magnesium sulfate for preeclampsia, the nurse must be vigilant for signs indicating magnesium toxicity, which requires immediate intervention. The assessment finding that would prompt the nurse to withhold the medication and notify the primary healthcare provider is the absence of deep tendon reflexes. This is an indication of magnesium toxicity, which is a serious and potentially life-threatening condition. Other signs of magnesium toxicity include respiratory depression, cardiac dysrhythmias, and altered mental status. Therefore, it is critical for nurses to monitor reflexes, respiratory rates, cardiac function, and urine output when administering magnesium sulfate.
Among the options provided:
- A urine output of 30 mL/h is within the acceptable range, as typically urine output should be at least 30 mL/h to ensure adequate kidney function.
- Respirations of 14 breaths/min are within normal range and would not necessitate withholding magnesium sulfate.
- A blood pressure of 140/100 mm Hg, while elevated, is not a direct indicator of magnesium toxicity and would require assessment in the context of the individual's overall clinical picture for preeclampsia management.