A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?

Difficulty in arousing

Deep tendon reflexes 2+

Urinary output of 30 mL per hour

Respiratory rate of 10 breaths/minute

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is incorrect because difficulty in arousing is a sign of magnesium toxicity, which is a serious complication of magnesium sulfate therapy. Magnesium toxicity can cause central nervous system depression, muscle weakness, and cardiac arrest. The nurse should monitor the client's level of consciousness and stop the infusion if the client becomes lethargic or unresponsive.

Choice B Reason: This is correct because deep tendon reflexes 2+ indicate a normal and expected response to magnesium sulfate therapy. Magnesium sulfate is a muscle relaxant that can reduce the risk of seizures in gestational hypertension. The nurse should assess the client's deep tendon reflexes regularly and maintain them at 2+ or slightly diminished.

Choice C Reason: This is incorrect because urinary output of 30 mL per hour is below the normal range of 40 to 80 mL per hour and may indicate renal impairment or dehydration. Magnesium sulfate can cause renal toxicity or fluid retention, which can affect the urinary output. The nurse should monitor the client's urinary output and fluid balance and report any abnormalities to the doctor.

Choice D Reason: This is incorrect because respiratory rate of 10 breaths/minute is below the normal range of 12 to 20 breaths/minute and may indicate respiratory depression. Magnesium sulfate can cause respiratory depression or failure, which can be life-threatening. The nurse should monitor the client's respiratory rate and oxygen saturation and administer oxygen or antidote if needed.

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Correct Answer is ["31"]

Explanation

The correct answer is 31 gtts/min. To calculate the infusion rate, the nurse should use the following formula:

Infusion rate (gtts/min) = Volume (mL) x Drop factor (gtts/mL) / Time (min)

Plugging in the given values, we get:

Infusion rate (gtts/min) = 1000 mL x 15 gtts/mL / 480 min

Infusion rate (gtts/min) = 31.25 gtts/min

Rounding to the nearest whole number, we get 31 gtts/min.

A. Homelessness B. Age C. BP 110/70 D. BMI 17.5 E. Prenatal care F. Prenatal history

Correct Answer is ["A","D","E","F"]

Explanation

Choice A Reason: Homelessness is a risk factor for high-risk pregnancy because it exposes the woman to various challenges and stressors that can affect her health and well-being. Homeless women may face difficulties in accessing adequate nutrition, hygiene, safety, shelter, transportation, and health care. They may also experience higher levels of violence, substance abuse, mental illness, and social isolation. These factors can increase the risk of infections, complications, preterm birth, low birth weight, and infant mortality.

Choice B Reason: Age is not a risk factor for high-risk pregnancy in this case because the woman is 22 years old, which is within the optimal age range for childbearing. The optimal age range is considered to be between 20 and 35 years old, as women in this age group tend to have fewer complications and better outcomes than women who are younger or older. Women who are younger than 20 or older than 35 are considered to have advanced maternal age or adolescent pregnancy, respectively, which are risk factors for high-risk pregnancy.

Choice C Reason: BP 110/70 is not a risk factor for high-risk pregnancy because it is within the normal range for blood pressure. The normal range for blood pressure is considered to be between 90/60 and 120/80 mmHg. Blood pressure that is too high or too low can indicate problems such as preeclampsia, eclampsia, or hypotension, which are risk factors for high-risk pregnancy.

Choice D Reason: BMI 17.5 is a risk factor for high-risk pregnancy because it indicates that the woman is underweight. BMI stands for body mass index, which is a measure of body fat based on height and weight. The normal range for BMI is considered to be between 18.5 and 24.9 kg/m2. BMI that is too low or too high can indicate problems such as malnutrition, obesity, or gestational diabetes, which are risk factors for high-risk pregnancy.

Choice E Reason: Prenatal care is a risk factor for high-risk pregnancy because it indicates that the woman has not received adequate medical attention and support during her pregnancy. Prenatal care is essential for ensuring the health and well-being of both the mother and the baby. Prenatal care involves regular visits to a health care provider who can monitor the progress of the pregnancy, screen for any complications or infections, provide education and counseling, and prescribe any necessary medications or interventions. Lack of prenatal care can increase the risk of maternal mortality, morbidity, preterm birth, low birth weight, congenital anomalies, and infant mortality.

Choice F Reason: Prenatal history is a risk factor for high-risk pregnancy because it indicates that the woman has had previous pregnancies that ended in miscarriage or stillbirth. Prenatal history can provide important information about the woman's reproductive health and potential complications that may recur or affect her current pregnancy. Previous pregnancy losses can indicate problems such as genetic abnormalities, chromosomal disorders, infections, immunological factors, hormonal imbalances, uterine abnormalities, or placental issues. These factors can increase the risk of spontaneous abortion, fetal demise, preterm birth, intrauterine growth restriction (IUGR), or placenta previa.

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A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["31"]

Explanation

Correct Answer is ["A","D","E","F"]

Explanation

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