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
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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Related Questions
Correct Answer is C
Explanation
A: This infection does not directly cause hearing loss at birth. Hearing loss in newborns can be associated with genetic factors, birth complications, and certain infections, but GBS is not known to be a direct cause of hearing impairment.
B: A positive GBS test result does not necessitate a cesarean birth. The standard management for GBS-positive mothers is the administration of intrapartum antibiotic prophylaxis, not cesarean delivery, unless there are other obstetric indications.
C: Testing for GBS is typically done between 36 and 37 weeks of gestation because this timing is close to delivery, when the test results are most predictive of the baby's risk of exposure during birth.
D: Antibiotics are not given during the last 2 weeks of pregnancy to prevent GBS transmission. Instead, they are administered during labor to ensure effective levels of the drug during delivery, which is the critical period for preventing transmission to the baby.
Correct Answer is B
Explanation
A. The shoulder harness should be placed between the breasts and off to the side of the gravid uterus, not directly across it. This helps reduce the risk of injury in the event of a crash.
B. Moving the seat as far away as possible from the steering wheel reduces the risk of injury from the steering wheel or airbag impact while still allowing the client to drive safely.
C. The lap belt should be worn low across the hips and under the abdomen, not high across the abdomen, to protect the growing fetus and prevent harm during sudden deceleration.
D. Airbags should not be disabled as they provide essential protection during a crash. Proper seatbelt use and correct seating position allow airbags to function effectively without posing a risk to the pregnant client.
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