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.
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Related Questions
Correct Answer is D
Explanation
A. Increasing the frequency of feedings from the affected nipple can worsen soreness. It’s important to address the underlying cause of soreness, which may involve evaluating latch technique or positioning rather than increasing feeding frequency.
B. Vitamin E oil is not recommended for sore nipples as it can cause irritation. Proper care involves managing latch and positioning, and sometimes using a lanolin cream rather than oils or other substances.
C. Washing the nipple with soap and water before each feeding can remove natural oils and lead to further irritation. The nipple should be gently cleaned with water, if necessary, and kept clean without over-washing.
D. Exposing the affected nipple to the air between feedings helps with healing and reduces moisture, which can exacerbate soreness. Allowing the nipple to air-dry can promote healing and reduce discomfort.
Correct Answer is []
Explanation
- Potential Condition: Endometritis. The symptoms of malaise, chills, decreased appetite, elevated temperature, tachycardia, a boggy and tender uterus, and foul-smelling lochia are indicative of a postpartum infection, such as endometritis.
- Actions to Take:
- Monitor the lochia amount and odor: This will help assess the presence of infection and the effectiveness of treatment.
- Assist with the administration of prescribed antibiotics: Antibiotics are the primary treatment for endometritis.
- Parameters to Monitor:
- Temperature: Monitoring for fever can help assess the response to treatment and indicate if the infection is resolving or worsening.
- Heart rate: Tachycardia may be a sign of infection or other complications, so it's important to monitor changes in heart rate.
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