A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia.
Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.
A.
Deep tendon reflexes
B.
Respiratory rate
C.
Urine output
D.
Fetal heart rate
E.
Serum magnesium level
To monitor for magnesium toxicity in a client receiving magnesium sulfate IV, the nurse should perform the following assessments:
A. Deep tendon reflexes
B. Respiratory rate
C. Urine output
E. Serum magnesium level
Explanation:
- A. Deep tendon reflexes: Magnesium toxicity can lead to reduced deep tendon reflexes. Monitoring these reflexes helps assess for signs of toxicity.
- B. Respiratory rate: Magnesium toxicity can cause respiratory depression. Regular monitoring of the respiratory rate helps detect potential toxicity.
- C. Urine output: Magnesium sulfate is excreted through the kidneys. Monitoring urine output helps ensure that the kidneys are functioning properly and prevents toxicity.
- E. Serum magnesium level: Regular monitoring of serum magnesium levels is crucial to assess for appropriate dosing and to prevent toxicity.
- D. Fetal heart rate: While monitoring the fetal heart rate is important in the overall management of preeclampsia, it is not a direct assessment for magnesium toxicity. However, it is essential to monitor for the well-being of the fetus.
Therefore, the correct assessments to monitor for magnesium toxicity are A, B, C, and E.