A nurse is administering magnesium sulfate IV to a client with severe preeclampsia for seizure prophylaxis. Which of the following are indications of magnesium sulfate toxicity? (Select all that apply.)
Flushing and sweating.
Decreased level of consciousness.
Urinary output less than 30 mL/hr.
Respirations fewer than 12/min.
Correct Answer : A,B,C,D
Choice A rationale
Flushing and sweating can be an indication of magnesium sulfate toxicity. Magnesium sulfate is a medication used to prevent seizures in women with severe preeclampsia. However, if the levels of magnesium become too high, it can lead to toxicity15.
Choice B rationale
A decreased level of consciousness can be an indication of magnesium sulfate toxicity. High levels of magnesium can affect the central nervous system, leading to drowsiness, lethargy, and decreased responsiveness15.
Choice C rationale
Urinary output less than 30 mL/hr can be an indication of magnesium sulfate toxicity. Magnesium sulfate can affect kidney function, leading to decreased urine output15.
Choice D rationale
Respirations fewer than 12/min can be an indication of magnesium sulfate toxicity. High levels of magnesium can depress the respiratory system, leading to slow or shallow breathing15.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Performing nasopharyngeal suctioning for a maximum of 5 seconds is not a recommended action for an infant diagnosed with Tetralogy of Fallot. This procedure is typically used to clear the airway in infants with respiratory distress, not heart conditions.
Choice B rationale
Positioning the infant in a knee-chest position can help increase blood flow to the lungs, which is beneficial for an infant with Tetralogy of Fallot. This condition involves a combination of heart defects that affect the normal flow of blood through the heart.
Choice C rationale
Administering morphine via IV bolus is not a recommended action for an infant diagnosed with Tetralogy of Fallot. While morphine is a powerful pain reliever, it is not typically used in the management of this condition.
Choice D rationale
Providing 100% oxygen by face mask is not a recommended action for an infant diagnosed with Tetralogy of Fallot. While supplemental oxygen can help increase the amount of oxygen in the blood, it does not address the underlying heart defects associated with this condition.
Correct Answer is C
Explanation
Choice A rationale
Erythema toxicum is a common rash seen in newborns, characterized by blotchy red spots on the skin with overlying white or yellow papules or pustules. It does not present as small white nodules on the roof of the mouth.
Choice B rationale
Mongolian spots are a type of birthmark that are flat, blue, or blue-gray. They appear at birth or in the first or second week of life. They look similar to bruises and are most often found on the buttocks or lower back, but are never found on the roof of the mouth.
Choice C rationale
Epstein pearls are small, harmless white or yellow nodules that may appear along your newborn baby’s gums or on the roof of their mouth. They are common and usually go away within three months after birth.
Choice D rationale
Milia spots are tiny white bumps that appear across a baby’s nose, chin or cheeks. Milia are common in newborns but can occur at any age. Unlike Epstein pearls, they do not appear on the roof of the mouth.
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