A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings is the nurse's priority?

Respiratory rate 10/min

2+ deep-tendon reflexes

3+ pedal edema

Urinary output 35 mL/hr

Answer and Explanation

The Correct Answer is A

A. Respiratory rate 10/min. This is the priority finding because it suggests respiratory depression, a serious side effect of magnesium sulfate therapy. Magnesium acts as a CNS depressant, and a respiratory rate below 12/min is a potential sign of magnesium toxicity, which can lead to respiratory arrest if not promptly addressed.
B. 2+ deep-tendon reflexes. This indicates normal neuromuscular function and is actually a reassuring finding in a client receiving magnesium sulfate. Reflexes are typically monitored to detect early signs of toxicity, and a 2+ rating means the dose is likely therapeutic.
C. 3+ pedal edema. While significant, pedal edema is a common feature of preeclampsia and not directly related to magnesium sulfate toxicity. It should be monitored but does not require immediate action compared to respiratory compromise.
D. Urinary output 35 mL/hr. This is slightly above the minimum acceptable output of 30 mL/hr, indicating the kidneys are excreting adequately. While magnesium is excreted renally and output must be monitored, this value does not indicate an acute risk.

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Correct Answer is D

Explanation

A. Use tubing that does not have a filter in the drip chamber. Blood transfusion tubing must have a filter to trap clots, cellular debris, and other particulates, ensuring the safe administration of blood products.
B. Use an IV catheter that is at least 24-gauge. A larger bore catheter (18- to 20-gauge) is preferred for blood transfusions to reduce the risk of hemolysis and allow adequate flow. A 24-gauge is too small for standard transfusion protocols.
C. Attach a single line administration set. A Y-type tubing set is typically used, allowing for connection to both the blood product and normal saline. This setup enables flushing before and after the transfusion and provides a safe delivery system.
D. Prime the tubing with 0.9% sodium chloride. Only 0.9% sodium chloride (normal saline) should be used to prime the tubing, as it is compatible with blood products and prevents hemolysis or clot formation. Dextrose or other solutions can cause serious reactions.

A. Changes from prone to sitting B. Rolls from back to abdomen C. Sits steadily unsupported D. Rolls from back to side

Correct Answer is D,B,C,A

Explanation

D. Rolls from back to side usually occurs around 4 months of age as the infant begins developing trunk strength.

B. Rolls from back to abdomen typically follows at around 5 to 6 months, indicating improved coordination and strength.

C. Sits steadily unsupported usually develops around 8 months, showing advanced balance and postural control.

A. Changes from prone to sitting is a more complex skill that typically appears around 10 months, requiring significant core strength and motor planning.

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A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a blood transfusion to a client, which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is teaching a group of parents about expected development of gross motor skills during infancy. The nurse should teach that the following developmental tasks are expected to occur in what order? (Move the steps into the box, placing them in the order of performance. Use all the steps.)

Correct Answer is D,B,C,A

Explanation

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