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
Explanation
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.
Correct Answer is D
Explanation
A. Incorrect. Periodic tingling of fingers is not typically considered a sign of a serious prenatal complication. It can be related to normal pregnancy changes such as carpal tunnel syndrome.
B. Incorrect. The absence of clonus is not indicative of a complication. Clonus, or the lack thereof, is a normal finding in the absence of significant neurological issues.
C. Incorrect. Leg cramps are a common issue during pregnancy and usually not a sign of a severe complication.
D. Correct. Blurred vision can be a sign of preeclampsia or other significant prenatal complications, and should be evaluated further to ensure proper management and safety for both the mother and fetus.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.