Final answer:
Immediate intervention by the nurse is required if the client shows signs of magnesium toxicity, which include respiratory depression, diminished or absent deep tendon reflexes, a sudden drop in blood pressure, or a significant decrease in urine output during treatment for severe preclampsia with magnesium sulfate.
Step-by-step explanation:
A client who is at 36 weeks gestations is admitted with severe preclampsia and is treated with a magnesium sulfate therapy. The assessment finding that warrants immediate intervention by the nurse would be signs of magnesium toxicity. Symptoms of toxicity include respiratory depression, diminished or absent deep tendon reflexes, a sudden drop in blood pressure, or a significant decrease in the urine output. The therapeutic range of magnesium sulfate is narrow, and nurses must vigilantly monitor for toxicity, especially when administering high doses intravenously.
Regular assessment of the client's deep tendon reflexes, respiratory rate, blood pressure, and urine output are crucial, as they can indicate the onset of magnesium toxicity. If any signs are present, it is imperative for the nurse to take immediate action, which may include stopping the magnesium infusion, administering calcium gluconate as an antidote, and notifying the physician.
Monitoring serum magnesium levels can also provide critical information regarding potential toxicity, but clinical signs must guide immediate intervention. Since the patient is at a high risk for complications due to severe preclampsia, continuous and close monitoring is essential for the safety of both the mother and the unborn child.