The nurse is monitoring a client with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)
a. Cool, clammy skin
b. Altered sensorium
c. Pulse oximeter reading of 95%
d. Respiratory rate of less than 12 breaths/min
e. Absence of deep tendon reflexes
ANS: B, D, E
Signs of magnesium toxicity include the following:
· Respiratory rate of less than 12 breaths/min (hospitals may specify a rate < 14 breaths/min)
· Maternal pulse oximeter reading lower than 95%
· Absence of deep tendon reflexes
· Sweating, flushing
· Altered sensorium (confused, lethargic, slurred speech, drowsy, disoriented)
· Hypotension
· Serum magnesium value above the therapeutic range of 4 to 8 mg/dL
Cold, clammy skin and a pulse oximeter reading of 95% would not be signs of toxicity.
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