A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion.
For which of the following therapeutic effects should the nurse monitor the client
A.
Deep tendon reflexes 2+.
B.
1+ proteinuria via urine dipstick.
C.
Pulse rate 100/min.
D.
Urine output 20 mL/hr.
E.
undefined
The Correct Answer and Explanation is:
The correct answer is A. Deep tendon reflexes 2+.
Explanation:
Magnesium sulfate is commonly used in the management of preeclampsia to prevent seizures, a condition known as eclampsia. The therapeutic effects and monitoring requirements for magnesium sulfate infusion are crucial for ensuring the safety and efficacy of the treatment. Monitoring deep tendon reflexes is an important aspect of this care.
Deep Tendon Reflexes: Magnesium sulfate acts as a central nervous system depressant and can affect neuromuscular function. It is essential to monitor deep tendon reflexes to assess the level of neuromuscular blockade and avoid toxicity. A reflex score of 2+ is considered normal, indicating that the reflexes are present and functioning appropriately. If reflexes diminish (e.g., 1+ or less), it could suggest that the magnesium levels are too high and the client may be at risk for magnesium toxicity. Severe magnesium toxicity can lead to a lack of reflexes, respiratory depression, and cardiac issues. Therefore, regular assessment of deep tendon reflexes helps in adjusting the magnesium sulfate dosage to maintain therapeutic levels and prevent adverse effects.
Other Options:
- B. 1+ proteinuria via urine dipstick: Monitoring proteinuria is essential for assessing the severity of preeclampsia, but it is not directly related to the therapeutic effects of magnesium sulfate. Proteinuria is an indicator of kidney function and the extent of renal involvement in preeclampsia.
- C. Pulse rate 100/min: While monitoring the pulse rate is important for overall cardiovascular health, it is not a specific indicator of magnesium sulfate’s therapeutic effects or potential toxicity. The pulse rate could be influenced by various factors unrelated to magnesium sulfate.
- D. Urine output 20 mL/hr: Monitoring urine output is crucial for assessing renal function and preventing complications related to fluid balance. However, a urine output of 20 mL/hr is considered low and could be indicative of renal impairment or other issues unrelated to magnesium sulfate therapy specifically.
In summary, monitoring deep tendon reflexes (option A) is the most directly relevant measure for assessing the therapeutic effects of magnesium sulfate in preventing seizures in a client with preeclampsia.