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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

Jarisch-Herxheimer reaction is seen in spirochete infections like syphilis or Lyme disease, not typically in pelvic inflammatory disease (PID) treated with antibiotics like levofloxacin and metronidazole.

Choice B rationale

Serial anaerobic cultures are not routine for PID management. Diagnosis and management focus more on clinical symptoms and empirical antibiotic therapy rather than continuous culture monitoring.

Choice C rationale

Supervised parenteral antibiotic protocols ensure proper dosage and administration, crucial for severe infections requiring hospitalization. Monitoring treatment in a controlled environment increases effectiveness and reduces complications.

Choice D rationale

While infection control is important, PID typically spreads through sexual contact, and hospital admission for infection control is not the primary reason. The focus is more on effective treatment delivery in severe cases. .

A. Have the antibiotic trough level drawn within 3 days. B. Continue strict monitoring of daily wet diapers for 1 week. C. Administer antipyretic medication on a continuous basis. D. Monitor the infant for response to auditory stimuli.

Correct Answer is D

Explanation

Choice A rationale

In bacterial meningitis, monitoring antibiotic levels is critical during treatment to ensure therapeutic effectiveness and avoid toxicity. However, it is not necessary to check antibiotic levels after completing the course. The body clears the antibiotics within a few days, and monitoring is more relevant during therapy.

Choice B rationale

While monitoring wet diapers is important during illness, it's not necessary to continue strict monitoring post-treatment. Wet diapers track hydration and renal function, which should normalize after successful treatment.

Choice C rationale

Continuous use of antipyretics is unnecessary post-treatment. Fever management is more critical during active infection. Post-treatment, fevers should subside, making continuous medication redundant and possibly harmful.

Choice D rationale

Auditory monitoring is crucial after meningitis due to the risk of hearing loss, a common complication. Early detection of auditory issues allows for timely intervention and support for the child’s development.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Upon completion of a 14-day antibiotic treatment for bacterial meningitis in an infant, the nurse prepares the family for discharge. Which information should the nurse include?

Correct Answer is D

Explanation

A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. Which action should the nurse implement first?

The healthcare provider prescribes magnesium sulfate 6 grams IV to be infused over 20 minutes for a client with preterm labor. The IV bag contains "Magnesium sulfate 20 grams in dextrose 5% in water 500 mL.”. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?

An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

The mother of a 4-month-old baby girl asks the nurse when she should introduce solid foods to her infant.The mother states, "My mother says I should put rice cereal in the baby's bottle now.”. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

During the admission process of a school-age child, the child states, "I'm going to have an operation.”. Which response is best for the nurse to provide to this child?

A client who is 38 weeks pregnant is concerned her baby might get a communicable disease before any immunizations are given. Which physiological mechanism should the nurse use when responding to the mother's concerns?