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?
These findings are within normal limits and require routine follow-up.
All findings are outside of the acceptable range and should be reported to the healthcare provider immediately.
The primary IV fluids should be increased to assist in increasing the urinary output.
The findings indicate potential toxicity to the magnesium sulfate and close follow-up is indicated.
The Correct Answer is B
Choice A rationale
While routine follow-up is necessary, these findings suggest magnesium sulfate toxicity, requiring immediate attention beyond routine monitoring. Hence, this is not the correct action.
Choice B rationale
Although reporting abnormal findings to the healthcare provider is critical, not all findings are necessarily outside acceptable ranges. This choice lacks the specificity needed in this context, making it less appropriate.
Choice C rationale
Increasing primary IV fluids could help with low urine output but would not address potential magnesium toxicity, which is the primary concern indicated by the assessment. Therefore, it is not the correct conclusion.
Choice D rationale
The findings suggest magnesium toxicity, including decreased respirations, reduced urine output, and deep tendon reflexes. Close follow-up, including immediate medical intervention, is needed to manage this potential toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Diaphragmatic respirations are a normal breathing pattern and do not indicate respiratory distress. In fact, diaphragmatic breathing can be beneficial for patients with respiratory conditions as it helps to maximize lung expansion and improve oxygenation. Therefore, this finding is not indicative of acute respiratory distress in a child with asthma.
Choice B rationale
Bilateral bronchial breath sounds are usually heard over the large airways, such as the trachea and the main bronchi, and are not typically associated with acute respiratory distress. Wheezing or diminished breath sounds would be more indicative of airway obstruction and respiratory distress in a child with asthma.
Choice C rationale
Flaring of the nares is a sign of increased respiratory effort and is commonly seen in children with acute respiratory distress. This indicates that the child is struggling to breathe and is using additional muscles to help with respiration, which is a concerning sign that requires immediate attention.
Choice D rationale
A resting respiratory rate of 35 breaths per minute is elevated for a 3-year-old child but is not the most specific sign of acute respiratory distress. While tachypnea can indicate respiratory distress, other signs, such as nasal flaring, retractions, and cyanosis, are more specific indicators of the severity of the child's condition. .
Correct Answer is C
Explanation
Choice A rationale
Requesting extra staff to help with the nursing assessments may not be the most effective approach. It could increase the child's anxiety due to the presence of more unfamiliar people in the room. The primary goal is to create a calm environment that helps the child feel safe and more cooperative.
Choice B rationale
Explaining the reasons for the examination to the child may not be effective for a preschooler who may not fully understand or be comforted by such explanations. Young children often require more tangible and immediate means of reassurance and distraction.
Choice C rationale
Talking to the mother and gradually focusing on the child's toy is a practical approach. This strategy helps build rapport with both the mother and the child, and using the toy as a focal point can distract and comfort the child, making the examination process less intimidating and more cooperative.
Choice D rationale
Completing the assessment while allowing the child to cry may not be ideal. It can increase the child's distress and make the assessment more challenging. Addressing the child's emotional needs by providing comfort and distraction can lead to a more successful and less stressful examination.
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