A nurse is assessing a client who is receiving magnesium sulfate as a treatment for preeclampsia. Which of the following clinical findings is the nurse's priority?
Urinary output 40 mL in 2 hr
Fetal heart rate 158/min
Reflexes +2
Respirations 16/min
The Correct Answer is A
A. Urinary output 40 mL in 2 hr: Oliguria (urine output < 30 mL/hr) is a sign of magnesium toxicity, which can lead to respiratory depression, loss of reflexes, and cardiac arrest. The kidneys excrete magnesium, and impaired renal function increases toxicity risk. This finding requires immediate action.
B. Fetal heart rate 158/min: A fetal heart rate of 158 bpm is within the normal range (110-160 bpm) and is not a priority concern.
C. Reflexes +2: A +2 reflex response is normal. In magnesium toxicity, reflexes become diminished or absent (+1 or 0), indicating neuromuscular depression.
D. Respirations 16/min: While respiratory depression is a concern with magnesium sulfate, a respiratory rate of 16 breaths/min is within normal limits (12-20 bpm) and does not require immediate intervention. However, monitoring is still necessary.
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Related Questions
Correct Answer is B
Explanation
A. Pyelonephritis in pregnancy does not pose any risks to the fetus. Pyelonephritis can lead to complications such as preterm labor, low birth weight, and maternal sepsis, making this statement incorrect.
B. Untreated pyelonephritis in pregnancy can increase the risk of preterm labor and low birth weight. Pyelonephritis can cause systemic inflammation, leading to complications such as preterm labor and fetal growth restriction. Prompt treatment is necessary to reduce these risks.
C. Pyelonephritis is a common condition during pregnancy. While urinary tract infections (UTIs) are common in pregnancy, pyelonephritis (kidney infection) is less frequent but more serious.
D. Pyelonephritis is a mild infection that does not require treatment. Pyelonephritis is a serious condition that requires immediate antibiotic therapy to prevent maternal and fetal complications.
Correct Answer is D
Explanation
A. Heart rate of 56/min. Bradycardia (HR <60/min) can indicate magnesium toxicity. Magnesium sulfate can depress the central nervous system, leading to cardiac complications.
B. Urine output of 50 mL in 4 hr. Urine output should be at least 30 mL/hr (120 mL in 4 hours). Oliguria (low urine output) may indicate magnesium toxicity due to impaired renal excretion.
C. Diminished deep-tendon reflexes. Mildly decreased reflexes may be expected with magnesium therapy, but absent or significantly diminished deep tendon reflexes (DTRs) are an early sign of magnesium toxicity.
D. Respiratory rate of 16/min. A respiratory rate of ≥12 breaths/min indicates that the client is not experiencing respiratory depression, a major concern with magnesium sulfate toxicity. Magnesium should be discontinued if respiratory rate drops below 12/min.
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