A nurse is assessing a client who is receiving IV magnesium sulfate for treatment of preeclampsia. Which of the following findings should the nurse report?
24 hr urine output 960 mL
Blood pressure 122/88 mm Hg
1+ deep tendon reflexes
Pupils equal, round, react to light, accommodation
The Correct Answer is C
A. Output above 30 mL/hr is acceptable and not concerning.
B. A BP of 122/88 is within normal limits.
C. A decrease in deep tendon reflexes (DTRs), such as 1+, can indicate magnesium toxicity and requires immediate intervention.
D. Normal pupillary findings do not indicate toxicity.
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Related Questions
Correct Answer is C
Explanation
A. Vomiting 30 mL of fluid is concerning but not immediately life-threatening in the context of morphine administration.
B. Urinary output of 20 mL in 1 hr is low, but it is not as urgent as respiratory depression.
C. Respirations deep at a rate of 10/min is a sign of respiratory depression, which is a priority concern in patients receiving opioids like morphine, as it can lead to hypoxia and respiratory failure.
D. Blood pressure 90/60 mm Hg is low but not as immediately concerning as respiratory depression in this scenario.
Correct Answer is C
Explanation
A. Diarrhea can be a common side effect of amoxicillin, but it is not an allergic reaction.
B. Nausea can also occur with amoxicillin, but it does not necessarily indicate an allergic reaction.
C. Laryngeal edema is a severe allergic reaction and can cause difficulty breathing, which is a medical emergency.
D. Cardiac dysrhythmia is not a typical sign of an allergic reaction to amoxicillin.
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