A client is on magnesium sulfate for pre-eclampsia, what assessments should be done hourly. Select all that apply.

deep tendon reflexes

edema

respirations

level of consciousness

heart rate

urine output

Answer and Explanation

Correct Answer : A,C,D,F

A. deep tendon reflexes: Magnesium sulfate acts as a central nervous system depressant by blocking neuromuscular transmission. The loss or diminution of the patellar reflex is the first clinical sign of rising serum magnesium levels. Hourly assessment allows for the early detection of neuromuscular blockade before respiratory arrest occurs.

B. edema: While peripheral and facial edema are characteristic findings in preeclamptic patients, they do not fluctuate rapidly enough to require hourly monitoring. Tracking fluid shifts is important for long-term management of third-spacing and pulmonary risk. It is not a primary indicator used to titrate or detect magnesium toxicity.

C. respirations: Toxicity from magnesium sulfate leads to progressive depression of the diaphragm and intercostal muscles. A respiratory rate below 12 breaths per minute indicates a dangerous accumulation of the drug in the systemic circulation. This assessment is the most critical parameter for preventing fatal respiratory failure during infusion.

D. level of consciousness: Central nervous system depression manifests as somnolence, slurred speech, or a decreased Glasgow Coma Scale score. As magnesium levels exceed the therapeutic range of 4 to 7 mEq/L, the patient may become increasingly lethargic. Hourly neurological checks ensure the patient remains alert and responsive to stimuli.

E. heart rate: Magnesium can cause peripheral vasodilation and a slight decrease in blood pressure, but it does not typically cause acute, toxic changes in heart rate. Tachycardia or bradycardia are not sensitive or specific markers for magnesium overdose. Monitoring focus remains on the respiratory and neuromuscular systems instead.

F. urine output: Magnesium sulfate is excreted almost exclusively by the kidneys, necessitating adequate renal perfusion for safe administration. Oliguria, defined as less than 30 mL per hour, leads to rapid drug accumulation and subsequent toxicity. Monitoring output ensures the kidneys are clearing the medication at a safe rate.

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Correct Answer is D

Explanation

A. Bloody show present: The passage of a blood-tinged mucus plug can occur days before the onset of actual labor or following a vaginal exam. While it indicates cervical softening, it is not a definitive diagnostic marker for active labor. It is considered a premonitory sign rather than a confirmation of labor.

B. Nitrazine test positive: A positive nitrazine test confirms the rupture of membranes by detecting the alkaline pH of amniotic fluid. While ROM often accompanies labor, it can occur prematurely without the presence of uterine contractions or cervical change. It does not provide evidence of active, progressive labor.

C. Vertex presentation at -1 station: Fetal station and presentation describe the position of the fetus within the birth canal but do not define labor status. A fetus can be at -1 station for weeks during the late third trimester. Labor is a functional process of uterine activity and cervical response.

D. Cervical changes noted from last exam 2 hours ago: True labor is clinically defined by progressive cervical effacement and dilation in response to regular uterine contractions. Without measurable change in the cervix over time, contractions are classified as false labor or Braxton Hicks. This is the gold standard for diagnosis.

A. at the beginning of the second stage B. at the end of the active phase C. during the latter part of the second stage D. during transition

Correct Answer is A

Explanation

A. at the beginning of the second stage: This stage is defined by complete cervical dilation of 10 centimeters and 100% effacement. Pushing at this point utilizes the Ferguson reflex to facilitate fetal descent through the birth canal. It ensures the cervix is no longer an obstruction.

B. at the end of the active phase: This phase concludes when dilation reaches approximately 8 centimeters. Pushing before full dilation can cause cervical edema, maternal exhaustion, and potential cervical lacerations. The birth canal is not yet physiologically prepared for the forceful expulsion of the fetus.

C. during the latter part of the second stage: While pushing is necessary here, it must be initiated as soon as the stage starts to ensure progress. Waiting until the head is crowning or the stage is nearly over prolongs labor. Early coordination of contractions and pushing is optimal.

D. during transition: This represents the final part of the first stage of labor. Although the urge to push is intense, the cervix is not yet fully dilated. Premature pushing during transition increases the risk of maternal soft tissue trauma and fetal distress.

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A client is on magnesium sulfate for pre-eclampsia, what assessments should be done hourly. Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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