A nurse is assisting with the care of a client who has a prescription for magnesium sulfate.Which of the following adverse effects should the nurse report to the provider?

Respiratory rate 10/min.

Urine output 160 mL in 4 hr.

Diaphoresis.

Nausea.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Respiratory rate of 10/min is a critical adverse effect, indicating potential respiratory depression due to magnesium sulfate, a serious and life-threatening condition requiring immediate intervention.

Choice B rationale

Urine output of 160 mL in 4 hours is lower than expected but not immediately life-threatening. It needs monitoring but is not as critical as respiratory rate.

Choice C rationale

Diaphoresis, or excessive sweating, can be a side effect of magnesium sulfate but is not life-threatening. It warrants attention but does not require immediate reporting.

Choice D rationale

Nausea is a common, less severe side effect of magnesium sulfate that does not indicate an urgent situation.

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Correct Answer is C

Explanation

Choice A rationale

A weak cry is not a typical manifestation of neonatal abstinence syndrome (NAS). NAS usually presents with a high-pitched, persistent cry due to central nervous system irritability.

Choice B rationale

Decreased muscle tone is not common in NAS. Infants with NAS often exhibit hypertonia, characterized by increased muscle tone and rigidity.

Choice C rationale

This statement is correct because an exaggerated Moro reflex is a common sign of NAS, indicating central nervous system hyperactivity in response to withdrawal from maternal drugs.

Choice D rationale

An infant with NAS does not console easily. They are often difficult to soothe due to irritability and discomfort from withdrawal symptoms. .

A. Each feeding should last between 20 and 30 minutes. B. Prepared formula can be stored in the refrigerator for up to 5 days. C. Refrigerate formula from a feeding for up to 4 hours for reuse. D. Wait until the end of the feeding to burp your baby.

Correct Answer is A

Explanation

Choice A rationale

Each feeding should last between 20 and 30 minutes to ensure the baby gets enough nutrition and to facilitate bonding time.

Choice B rationale

Prepared formula should be used within 24 hours if stored in the refrigerator, not 5 days, to prevent bacterial growth and ensure the baby's safety.

Choice C rationale

Formula left at room temperature should not be refrigerated for reuse; it can develop bacteria that may harm the baby.

Choice D rationale

It is recommended to burp the baby multiple times during feeding to release swallowed air and prevent discomfort or spitting up.

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A nurse is assisting with the care of a client who has a prescription for magnesium sulfate.Which of the following adverse effects should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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