Which assessment finding would convince the nurse to "hold" the next dose of magnesium sulfate?
a. Absence of deep tendon reflexes
b. Urinary output of 100 ml total for the previous 2 hours
c. Respiratory rate of 14 breaths/minute
d. Decrease in blood pressure from 160/100 to 140/85
A
Because absence of deep tendon reflexes is a sign of magnesium toxicity, the next scheduled dose should not be administered. Calcium gluconate is the antidote that should be administered. An hourly output of less than 30 ml could indicate toxicity. A respiratory rate of less than 12 breaths/minute could indicate toxicity. A decrease in blood pressure is an expected side effect of magnesium sulfate.
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