A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy. For which of the following adverse effects should the nurse monitor and report to the provider?

Hyporeflexia

Tachypnea

Polyuria

Agitation

Answer and Explanation

The Correct Answer is A

A. Hyporeflexia is a significant adverse effect of magnesium sulfate therapy and can indicate magnesium toxicity. It is essential for the nurse to monitor deep tendon reflexes as part of the assessment when a client is receiving this medication. A decrease in reflexes may warrant immediate intervention and reporting to the provider.
B. Tachypnea is not a common adverse effect of magnesium sulfate; however, if it occurs, it may indicate respiratory distress, which should be assessed further.
C. Polyuria is not a typical adverse effect of magnesium sulfate. In fact, magnesium can lead to decreased urine output in some cases, especially with toxicity.
D. Agitation is also not a typical adverse effect of magnesium sulfate. Clients receiving magnesium sulfate may exhibit sedation rather than agitation.

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Correct Answer is B

Explanation

A. applying petroleum jelly to the suppository, is not necessary and may interfere with the medication's absorption.
B. Inserting the suppository along the posterior vaginal wall as far up as one can go.
C. inserting the suppository 5 cm (2 in), is the incorrect technique for administering a vaginal suppository. It should be administered as high up as one comfortably can
D. assisting the client into a prone position, is unnecessary and not related to the administration of the suppository.

A. "You will not be able to eat or drink anything for 8 hours prior to the test." B. "You will press the provided button when you feel the baby moving during the test." C. "You will receive medication through an IV line to stimulate contractions." D. "You will be required to lie flat on your back for the duration of the test."

Correct Answer is B

Explanation

A. There is no fasting requirement for a nonstress test.
B. The client will press a button whenever they feel the baby move during the test to help correlate fetal movement with changes in the fetal heart rate.
C. A nonstress test is not meant to stimulate contractions. It monitors the fetal heart rate in response to the baby's movements.
D. While the client will be monitored, they are not required to lie flat on their back for the entire duration of the test. They may be in a semi-reclining or comfortable position.

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A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy. For which of the following adverse effects should the nurse monitor and report to the provider?

Nursing Test Bank

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