A nurse is assessing a client who has preeclampsia and received a dose of calcium gluconate to treat magnesium sulfate toxicity.
Which of the following findings should the nurse identify as an indication that calcium gluconate was effective?
Respiratory rate 12/min.
Absent deep tendon reflexes.
Slurred speech.
Urine output 22 mL/hr.
The Correct Answer is A
Choice A rationale
A respiratory rate of 12/min indicates that the respiratory depression caused by magnesium sulfate toxicity has been effectively reversed by calcium gluconate. Normal respiratory rate in adults is 12-20 breaths per minute.
Choice B rationale
Absent deep tendon reflexes indicate ongoing magnesium sulfate toxicity. Calcium gluconate administration should restore normal reflexes, not cause their absence.
Choice C rationale
Slurred speech is a sign of magnesium sulfate toxicity. Effective treatment with calcium gluconate should improve neurological function and resolve symptoms like slurred speech.
Choice D rationale
A urine output of 22 mL/hr is below the normal range and suggests renal impairment or ongoing toxicity. Effective treatment should result in an increase in urine output to within the normal range (greater than 30 mL/hr).
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Preparing for a cesarean birth is not an immediate necessity unless there are complications that warrant such intervention. Cesarean births are typically reserved for situations where vaginal delivery poses a risk to the mother or the baby.
Choice B rationale
Administering IV antibiotic prophylaxis is critical in preventing potential infections during the labor process, especially given the early gestation period. This helps in safeguarding both the mother and the fetus from infections like group B streptococcus.
Choice C rationale
Obtaining a vaginal culture is generally done to check for infections such as bacterial vaginosis or sexually transmitted infections. However, it is not an immediate priority when the patient is already in active labor.
Choice D rationale
Administering metronidazole orally is used to treat bacterial infections but is not an immediate action required in this scenario. Metronidazole may not be the most suitable choice during labor as it does not provide immediate infection prevention.
Correct Answer is D
Explanation
Choice A rationale
A shrill cry may indicate distress but isn't specifically related to hypoglycemia in newborns.
Choice B rationale
Weak peripheral pulses are more commonly associated with circulatory or cardiac issues rather than hypoglycemia.
Choice C rationale
Yellowish skin suggests jaundice, which is due to elevated bilirubin levels, not hypoglycemia.
Choice D rationale
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns, indicating a need to check blood glucose levels.
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