A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

Drowsiness

Facial flushing

Nausea

Respiratory depression

Answer and Explanation

The Correct Answer is D

Explanation:

A. Drowsiness: Mild drowsiness is a common side effect of magnesium sulfate therapy and is not necessarily indicative of toxicity. However, severe drowsiness or lethargy can be a sign of magnesium toxicity and should be reported to the provider.

B. Facial flushing: Facial flushing is a common side effect of magnesium sulfate administration and is generally not a sign of toxicity. It is often accompanied by warmth and redness of the skin but is not considered a serious adverse reaction.

C. Nausea: Nausea is another common side effect of magnesium sulfate therapy and is usually mild and transient. It is not typically indicative of toxicity unless it is severe and persistent.

D. Respiratory depression: Respiratory depression is a critical sign of magnesium toxicity. Excessive levels of magnesium can affect neuromuscular function, leading to respiratory muscle weakness and depression. This can result in shallow or slowed breathing, decreased oxygenation, and potential respiratory failure. Respiratory depression is a serious complication that requires immediate intervention, and the nurse should report it to the provider promptly.

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Correct Answer is A

Explanation

Explanation:

A. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone."

This response is accurate and informative. It explains that urinary frequency is a common symptom during early pregnancy due to hormonal changes and pressure on the bladder. It also provides a general timeline by stating that, in most cases, urinary frequency improves by the 12th week as the uterus rises out of the pelvis. Additionally, it mentions that poor bladder tone can contribute to ongoing urinary frequency, acknowledging individual differences.

B. "It occurs during the first trimester and near the end of the pregnancy."

This response is not accurate. While urinary frequency is common during the first trimester due to hormonal changes and pressure on the bladder, it typically improves rather than occurring again near the end of pregnancy. Mentioning both the first trimester and near the end of pregnancy could be confusing and misleading for the client.

C. "There is no way to predict how long it will last in each individual client."

While there can be individual variations in how long urinary frequency lasts during pregnancy, there are general trends and common timelines for this symptom. This response may be seen as somewhat dismissive or uninformative since it does not provide any guidance or context for the client's question.

D. "It's a minor inconvenience, which you should ignore."

This response is not appropriate as it dismisses the client's concerns about urinary frequency. While urinary frequency is a common symptom during pregnancy, it can still be uncomfortable for some individuals, and healthcare providers should acknowledge and address their concerns rather than suggesting they ignore them.

A. Assess maternal blood glucose. B. Place the client in Trendelenburg position. C. Prepare for an emergency cesarean birth. D. Discontinue the medication infusion.

Correct Answer is D

Explanation

Explanation:

A. Assess maternal blood glucose:

While assessing blood glucose levels is important in clients receiving magnesium sulfate due to its potential effects on blood sugar, it is not the priority action in this scenario. The client's respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity, which can lead to respiratory depression and neuromuscular effects. Therefore, the immediate concern is addressing the magnesium toxicity rather than assessing blood glucose levels.

B. Place the client in Trendelenburg position:

Placing the client in Trendelenburg position is not indicated for magnesium toxicity. The Trendelenburg position involves placing the client in a supine position with the legs elevated higher than the head. While this position may be used in some situations (e.g., hypotension), it is not appropriate for treating magnesium toxicity, respiratory depression, or absent deep-tendon reflexes. Placing the client in Trendelenburg position may worsen respiratory function and is not recommended in this case.

C. Prepare for an emergency cesarean birth:

While severe preeclampsia or eclampsia may necessitate emergency cesarean birth in some cases, it is not the immediate action needed for a client experiencing respiratory depression and absent deep-tendon reflexes due to magnesium sulfate toxicity. Cesarean birth is not the appropriate response to magnesium toxicity and would not address the client's current respiratory and neuromuscular issues. Therefore, preparing for an emergency cesarean birth is not the correct action in this scenario.

D. Discontinue the medication infusion:

This is the correct action to take. A respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity. Magnesium sulfate, while effective in preventing seizures in preeclampsia, can lead to respiratory depression and affect neuromuscular function at toxic levels. Discontinuing the medication infusion is crucial to prevent further magnesium toxicity and adverse effects on the client's respiratory and neuromuscular status. It is the immediate and priority action needed to address the client's current condition.

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A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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