A client in preterm labor has had an infusion of magnesium sulfate running for 8 hours. Current assessment findings are respirations of 14 breaths/minute, a urine output of 25 mL/hr, deep tendon reflexes of 1+, and a serum magnesium level of 8 mEq/L (4 mmol/L). Based on these assessment findings, which conclusion should the nurse reach? Reference Range: Magnesium [1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L)]

A. All findings are outside of acceptable range and should be reported to the healthcare provider immediately: While some findings are abnormal, immediate reporting is critical only for severe toxicity or life-threatening changes. B. The primary IV fluids should be increased to assist in increasing the low urinary output: Increasing IV fluids without addressing magnesium toxicity could worsen complications. The low urine output may be a sign of impaired renal excretion of magnesium, increasing the risk of toxicity. C. These findings are within normal limits and require routine follow up: The patient’s magnesium level (8 mEq/L) is significantly above the therapeutic range (1.3–2.1 mEq/L), respiratory rate is at the lower end, and DTRs are depressed, indicating abnormal findings. D. The findings indicate potential toxicity to the magnesium sulfate and close follow up is indicated: Depressed deep tendon reflexes, reduced urine output, borderline low respirations, and an elevated serum magnesium level indicate early magnesium toxicity. Close monitoring, holding or reducing the infusion, and preparing for antidote administration (calcium gluconate) are appropriate next steps.