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"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notifying the provider may be necessary if the problem persists, but the first step is to address the most likely cause of the deviation.
B. A fundus that is firm but deviated to the left suggests that the bladder may be distended. Emptying the bladder can help the uterus to return to its midline position and promote proper uterine involution.
C. Monitoring perineal pads for clots is important, but the first action should be to resolve the potential cause of the fundal deviation.
D. Administering an analgesic is not a priority action for addressing fundal deviation.
Correct Answer is D
Explanation
A. Petroleum jelly should be applied to prevent the diaper from sticking to the circumcision site, but it will not stop bleeding. Bright red blood oozing indicates that immediate action is needed to control bleeding.
B. Securing a clean diaper snugly could apply pressure but may not be the most effective method for controlling bleeding. It is more important to manage the bleeding directly by applying pressure.
C. Rinsing the newborn's penis with cool water is not an appropriate action for controlling bleeding. Cool water might be used for cleaning but does not address the issue of bleeding from the circumcision site.
D. Applying gentle pressure using a sterile dry gauze pad is the correct action to manage the bleeding. This method helps to control the bleeding by providing direct pressure to the site, which is crucial for addressing the issue.
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