Before administering magnesium sulfate to a woman with severe gestational hypertension, the nurse assesses her status. Which finding would cause the nurse to withhold the drug?
a. Patellar reflexes +3
b. Blood pressure 110/86 mm Hg
c. Respiratory rate 18 breaths/minute
d. Urinary output 20 mL/hour
ANS: D
Magnesium sulfate is primarily excreted by the kidneys. Therefore, if it is given to a patient with inadequate kidney function, it may accumulate and cause toxicity. Urinary output should be at least 30 mL/hr. The other findings are within normal limits.
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