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 C

Explanation

A. Expecting docusate sodium to produce a semi-fluid stool within 6 to 12 hours is incorrect. Docusate sodium is a stool softener that usually works within 1 to 3 days, not as quickly as 6 to 12 hours.
B. Decreasing the intake of high-fiber foods while taking docusate sodium is not advised. In fact, maintaining a high-fiber diet is essential for managing constipation effectively.
C. Taking docusate sodium with a full 8-ounce glass of water is correct. Adequate fluid intake is necessary to help the stool soften and facilitate bowel movements when using this medication.
D. Avoiding citrus fruits while taking docusate sodium is not necessary. Citrus fruits can be beneficial as part of a high-fiber diet to help alleviate constipation.

A. "My baby doesn't need to wear the security tag when staying in the room with me." B. "I can give the nurse a list of authorized family members who can pick up my baby from the nursery." C. "The staff member who comes to take my baby's picture will be wearing a photo identification badge." D. "I will ensure that my baby has one identification band on during our hospital stay."

Correct Answer is C

Explanation

Choice A is incorrect because security tags are a vital part of hospital security protocols to prevent newborn abduction, and they should be worn at all times, even when the baby is in the room with the parent.

Choice B is incorrect as while it is important to have a list of authorized individuals, it does not directly prevent abduction; the staff still needs to verify each person's identity before allowing them to take the baby.

Choice C is correct because it demonstrates the client's understanding that all hospital staff should have proper identification, especially when they are involved in newborn care, which is a critical security measure.

Choice D is incorrect because having only one identification band is insufficient; multiple forms of identification for both the parent and the newborn are necessary to ensure the baby's safety and prevent any mix-up or abduction.

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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

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and has a new prescription for docusate sodium to treat constipation. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is reinforcing teaching about the prevention of newborn abduction with a client who gave birth 8 hr ago. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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