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. Abruptio placentae: Correct. Continuous abdominal pain and vaginal bleeding, especially in a client with a history of cocaine use, suggest abruptio placentae. Cocaine use is a significant risk factor for this condition, where the placenta detaches prematurely from the uterine wall.
B. Hydatidiform mole: Incorrect. Hydatidiform mole, or molar pregnancy, typically presents with abnormal vaginal bleeding early in pregnancy, not at 38 weeks of gestation.
C. Preterm labor: Incorrect. While preterm labor can involve abdominal pain and bleeding, the specific combination of continuous abdominal pain and vaginal bleeding with a history of cocaine use is more indicative of abruptio placentae.
D. Placenta previa: Incorrect. Placenta previa generally causes painless bleeding, not continuous abdominal pain. It also usually presents earlier in pregnancy.
Correct Answer is B
Explanation
A. Nevus flammeus: Incorrect. Nevus flammeus, or port-wine stain, is a type of birthmark and does not present as swelling. It is a flat, pink or red mark on the skin.
B. Caput succedaneum: Correct. Caput succedaneum is swelling of the soft tissues of the newborn's head that crosses suture lines. It is caused by the pressure exerted during delivery, often with vacuum extraction.
C. Cephalohematoma: Incorrect. Cephalohematoma is a collection of blood between the skull and periosteum and does not cross suture lines. It is usually confined to one side of the head.
D. Erythema toxicum: Incorrect. Erythema toxicum is a common newborn rash with small red spots and pustules and is not associated with swelling that crosses suture lines.
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