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 A
Explanation
Choice A rationale
Projectile vomiting in an infant with an olive-like mass in the abdomen suggests pyloric stenosis. This condition causes severe vomiting due to gastric obstruction. It's a hallmark symptom and requires monitoring and surgical intervention.
Choice B rationale
While arching the back can occur in various conditions, it is not specifically indicative of pyloric stenosis. It could be a sign of discomfort or other neurological issues but not directly related to the gastrointestinal obstruction seen in pyloric stenosis.
Choice C rationale
Frequent pauses during feeding are common in many infant conditions and are not specific to pyloric stenosis. They indicate general feeding difficulties but are not diagnostic of this particular condition.
Choice D rationale
Coffee-ground emesis indicates bleeding in the gastrointestinal tract but is not typical of pyloric stenosis. The hallmark sign is non-bloody, forceful vomiting due to gastric outlet obstruction.
Correct Answer is D
Explanation
Choice A rationale
Typing and crossmatching for a possible transfusion is not the immediate priority for a child with hemophilia who has a swollen knee. While a transfusion might be necessary if there is significant bleeding, initial management should focus on controlling the bleeding and minimizing joint damage.
Choice B rationale
Initiating an IV site and beginning infusing normal saline is not the first action to take in this scenario. While IV access might be needed later, immediate measures should focus on controlling bleeding and reducing swelling to prevent further damage to the knee joint.
Choice C rationale
Monitoring the child's vital signs frequently is important, but it is not the first action to take. The priority is to control the bleeding and reduce the swelling, which are the immediate concerns in this situation.
Choice D rationale
Applying an ice pack and compression dressing to the knee is the first action to take. This helps to control bleeding, reduce swelling, and minimize joint damage. This is a crucial step in managing hemophilia-related injuries and should be done immediately upon recognizing a swollen joint.
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