A client on 2 gm/hr of magnesium sulfate has decreased deep tendon reflexes. Identify the priority nursing assessment to ensure client safety
. Assess uterine contractions continuously.b. Assess fetal heart rate continuously.c. Assess urinary output.d. Assess respiratory rate.
ANS: d
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a. Monitoring contractions does not indicate magnesium toxicity.
b. Magnesium sulfate will decrease fetal variability and not provide an accurate assessment of magnesium toxicity.
c. Urinary output does not correlate to decreased deep tendon reflexes.
d. Correct. Respiratory effort and deep tendon reflexes (DTRs) are involuntary, and a decrease in DTRs could indicate the risk of magnesium sulfate toxicity and the risk for decreased respiratory effort.
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