Question

A woman who is 38-Weeks gestation is receiving magnesium Sulfate for severe preclampsia. Which assessment finding warrants immediate intervention the nurse?

A) Respiratory rate of 16 breaths per minute
B) Blood pressure of 140/90 mmHg
C) Urinary output of 30 mL/hour
D) Absence of deep tendon reflexes (DTRs)

Answer 1

The absence of deep tendon reflexes (DTRs) in a 38-weeks pregnant woman receiving magnesium sulfate for severe pre-eclampsia requires immediate intervention by the nurse, as it may indicate magnesium toxicity.

Step-by-step explanation:

A woman who is 38-weeks gestation is receiving magnesium sulfate for severe pre-eclampsia. The assessment finding that warrants immediate intervention by the nurse is D) Absence of deep tendon reflexes (DTRs). Magnesium sulfate is a medication used in obstetrics to prevent seizures in women with pre-eclampsia, but it can also cause respiratory depression and other side effects. The absence of DTRs can be a sign of magnesium toxicity, which is potentially serious and requires urgent medical attention. Other listed findings such as a respiratory rate of 16 breaths per minute, blood pressure of 140/90 mmHg, and urinary output of 30 mL/hour are within normal or acceptable ranges for a woman with severe pre-eclampsia receiving this treatment. The absence of deep tendon reflexes indicates magnesium sulfate toxicity, which can lead to respiratory depression and other serious complications. It is essential to monitor for signs of magnesium toxicity, including absent or decreased deep tendon reflexes, and take prompt action to prevent further complications. The other options, while important to monitor, may not indicate magnesium sulfate toxicity and its associated risks.