A nurse is assisting with the care of a client who received magnesium sulfate to treat preterm labor. The nurse should monitor the client for which of the following findings as an indication of magnesium sulfate toxicity?

"Respiratory rate 10/min"

"Urine output 40 mL/hr"

"Nausea"

"Facial flushing"

Answer and Explanation

The Correct Answer is A

A. A respiratory rate of 10/min indicates magnesium sulfate toxicity, which can cause respiratory depression. Close monitoring of respiratory rate is essential to identify and manage potential toxicity.
B. Urine output of 40 mL/hr is not an immediate sign of toxicity but requires monitoring. Decreased urine output can be a sign of complications, but it is not the primary indicator of magnesium sulfate toxicity.
C. Nausea is a common side effect of magnesium sulfate but not necessarily indicative of toxicity. More severe symptoms like respiratory depression are critical for diagnosing toxicity.
D. Facial flushing is a common, mild side effect of magnesium sulfate and not a sign of toxicity. Monitoring for more severe symptoms is essential to assess for toxicity.

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Correct Answer is B

Explanation

A. The urinary catheter is usually removed within the first 24 hours after a cesarean birth, not 48 hours. Early removal helps prevent complications and promotes recovery.
B. Uterine massage is performed to prevent postpartum hemorrhage and ensure the uterus is contracting properly. This practice is part of standard postpartum care to promote uterine involution.
C. Postoperative diet progression typically starts with clear liquids and advances as tolerated. Regular food is introduced once the client can swallow safely and shows no signs of nausea or gastrointestinal issues.
D. Staying flat on the back is not required post-cesarean section. Early ambulation is encouraged to prevent complications like deep vein thrombosis and to promote healing.

A. Blood pressure 156/80 mm Hg B. Temperature 38.3° C (101° F) C. Respiratory rate 32/min D. Apical pulse 66/min E. None F. None

Correct Answer is C

Explanation

A. Blood pressure 156/80 mm Hg is incorrect. While this blood pressure reading is elevated, hypertension is not a typical immediate sign of postpartum hemorrhage. Hemorrhage is more commonly associated with hypotension (low blood pressure) due to fluid loss.

B. Temperature 38.3° C (101° F) is incorrect. A mild fever may be common in the first 24 hours postpartum due to normal inflammatory responses. It is not specifically indicative of postpartum hemorrhage, though a persistent fever could indicate an infection.

C. Respiratory rate 32/min is correct. An increased respiratory rate can be a sign of hypovolemia (due to significant blood loss), which may occur with postpartum hemorrhage. The body compensates for decreased blood volume by increasing the respiratory rate.

D. Apical pulse 66/min is incorrect. A heart rate of 66/min is within normal limits and would not be indicative of postpartum hemorrhage. In fact, a tachycardic (elevated) heart rate is more concerning in the case of hemorrhage as the body tries to compensate for blood loss.

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A nurse is assisting with the care of a client who received magnesium sulfate to treat preterm labor. The nurse should monitor the client for which of the following findings as an indication of magnesium sulfate toxicity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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