A nurse is assisting with the care of a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?
Respiratory rate of 16/min.
Heart rate of 60/min.
Urine output of 50 mL in 4 hr.
Diminished deep-tendon reflexes.
The Correct Answer is A
The correct answer is choice A: Respiratory rate of 16/min.
Choice A rationale:
A respiratory rate of 16/min is within the normal range for adults, which is typically between 12 to 20 breaths per minute. In the context of severe preeclampsia, maintaining a normal respiratory rate is crucial when administering magnesium sulfate IV, as one of the signs of magnesium toxicity is respiratory depression. Therefore, a respiratory rate of 16/min indicates that the client is not experiencing respiratory depression and it is safe to continue the magnesium sulfate infusion.
Choice B rationale:
A heart rate of 60/min is at the lower end of the normal range, which is 60 to 100 beats per minute for adults. However, bradycardia or a low heart rate can be a sign of magnesium sulfate toxicity, especially if accompanied by other symptoms such as hypotension or altered mental status. Without additional context, a heart rate of 60/min alone does not necessarily indicate it is unsafe to continue the infusion, but it would require further assessment.
Choice C rationale:
A urine output of 50 mL in 4 hours is significantly below the expected minimum of 30 mL/hour for adults. Adequate urine output is an important indicator of kidney function and is essential for the excretion of magnesium. In the case of magnesium sulfate infusion for severe preeclampsia, a low urine output could indicate renal insufficiency and an increased risk of magnesium toxicity. Therefore, a urine output of 50 mL in 4 hours is a contraindication for continuing the infusion without further evaluation.
Choice D rationale:
Diminished deep-tendon reflexes can be a sign of magnesium toxicity. Deep-tendon reflexes are assessed to monitor for signs of magnesium overdose during infusion, as magnesium acts as a central nervous system depressant at high levels. If deep-tendon reflexes are diminished, it may suggest that the serum magnesium levels are too high, and the infusion should be paused or discontinued to prevent further toxicity.
In summary, the only finding that clearly indicates it is safe to continue the magnesium sulfate infusion is a normal respiratory rate, as provided in choice A. The other options either require further assessment or are indicators of potential magnesium toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should recommend the client to increase cellulose and fluid in the diet. Cellulose is a type of fiber found in fruits, vegetables, and whole grains. Increasing fiber intake can help alleviate constipation by adding bulk to the stool and promoting regular bowel movements. Additionally, the recommendation to increase fluid intake complements the effect of fiber, as it softens the stool, making it easier to pass through the intestines. This combination of increased cellulose and fluid intake is a safe and natural way to address constipation during pregnancy without the need for medication or invasive interventions.
Choice B rationale:
Regular use of glycerine suppositories is not the best recommendation for pregnant clients experiencing constipation. Suppositories are inserted into the rectum to stimulate bowel movements and should only be used sparingly when other methods have failed. Pregnant individuals may have increased sensitivity, and it's essential to avoid unnecessary procedures or potential discomfort.
Choice C rationale:
Regular use of a laxative is also not the most suitable recommendation for a pregnant client with constipation. While laxatives can provide relief, they may lead to dependency and might have adverse effects on the developing fetus. It is best to explore safer and more natural methods before resorting to laxative use during pregnancy.
Choice D rationale:
Maintenance of good posture is essential during pregnancy for various rationales, but it is not a specific solution for constipation. While maintaining good posture can help alleviate back pain and other discomforts, it does not directly address the issue of constipation.
Correct Answer is ["A","B","E"]
Explanation
The correct answers are choices A. Blood pressure, B. Cerebral manifestations, and E. Deep tendon reflexes.
Choice A rationale:
Blood pressure is a critical parameter to monitor, especially in the third trimester. Elevated blood pressure can indicate preeclampsia, a serious condition that requires immediate attention.
Choice B rationale:
Cerebral manifestations, such as headaches or visual disturbances, can also be signs of preeclampsia. These symptoms should be reported to the provider immediately.
Choice C rationale:
The fetal heart rate of 158/min is within the normal range (110-160 beats per minute) and does not need to be reported.
Choice D rationale:
The respiratory rate is not mentioned in the provided notes, and there is no indication that it is abnormal. Therefore, it does not need to be reported.
Choice E rationale:
Deep tendon reflexes that are hyperactive (3+) can be a sign of preeclampsia. This finding should be reported to the provider.
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