A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?
Respiratory rate 11/min
Deep tendon reflexes 2+
Urine output 30 mL/hr
Blood pressure 100/62 mm Hg
The Correct Answer is A
A. Respiratory rate 11/min: Correct. A respiratory rate of 11/min is below the normal range and could indicate magnesium sulfate toxicity, which can depress respiratory function. This finding requires prompt reporting to prevent further complications.
B. Deep tendon reflexes 2+: Incorrect. Deep tendon reflexes of 2+ are within the normal range and are not indicative of magnesium sulfate toxicity. Normal reflexes suggest that the magnesium level is likely within the therapeutic range.
C. Urine output 30 mL/hr: Incorrect. While urine output should be monitored in clients receiving magnesium sulfate, 30 mL/hr is on the lower end of normal but not necessarily an immediate cause for concern unless it is persistently low or accompanied by other symptoms.
D. Blood pressure 100/62 mm Hg: Incorrect. This blood pressure reading is within the acceptable range for a pregnant client on magnesium sulfate. Magnesium sulfate is used to prevent seizures and does not typically affect blood pressure in this manner.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A,B"}}
Explanation
• Uterine tone
o Placenta previa: Not typically associated with abnormal uterine tone.
o Abruptio placenta: Associated with hard and rigid abdomen, uterine hypertonicity, and tenderness.
• Vaginal bleeding characteristics
o Placenta previa: Typically characterized by bright red, painless vaginal bleeding.
o Abruptio placenta: Often associated with dark red, painful vaginal bleeding.
• Pain rate
o Placenta previa: Usually presents with minimal or no pain.
o Abruptio placenta: Associated with sudden, severe abdominal pain and tenderness.
• Client weeks of gestation
o Placenta previa: Commonly diagnosed later in pregnancy, around 30 weeks or later.
o Abruptio placenta: Can occur at any point after 20 weeks of gestation, but often seen closer to term.
Correct Answer is D
Explanation
A. Request a prescription for PRN aspirin from the provider.: Incorrect. Aspirin should not be given with heparin as it can increase the risk of bleeding.
B. Massage the injection site thoroughly following administration.: Incorrect. The injection site should not be massaged after administering heparin to avoid irritation and potential hematoma formation.
C. Instruct the client that they cannot breastfeed while receiving heparin.: Incorrect. Heparin is generally considered safe to use during breastfeeding, so there is no need to instruct the client to stop breastfeeding.
D. Administer the injection in the client's abdomen.: Correct. Subcutaneous heparin injections are typically administered in the abdomen to facilitate absorption and minimize complications.
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