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 A
Explanation
A. Group B Streptococcus (GBS) status is typically re-evaluated at around 36 weeks of gestation to determine if prophylactic antibiotics are needed during labor to prevent transmission to the baby.
B. A positive GBS test does not automatically indicate a cesarean birth. Intravenous antibiotics during labor are generally used to prevent transmission of GBS to the newborn.
C. GBS infection can cause serious complications in newborns, but hearing loss is not a typical outcome. The primary concerns are sepsis, pneumonia, and meningitis.
D. Antibiotics for GBS are given during labor, not the last two weeks of pregnancy. The treatment aims to reduce the risk of GBS transmission to the baby during delivery.
Correct Answer is B
Explanation
A. Placing a rolled blanket behind the newborn’s neck is unsafe and can cause improper positioning in the car seat. The newborn should be positioned properly according to the car seat manufacturer's instructions to ensure safety during travel.
B. The car seat should be positioned at a 45° angle to keep the newborn’s airway open and prevent slumping. This angle supports proper head and neck alignment, which is essential for the baby’s safety and comfort during travel.
C. The retainer clip should be positioned at the level of the newborn’s armpits, not the umbilicus. Proper placement of the retainer clip ensures that the harness is secure and correctly positioned over the baby’s shoulders.
D. Newborns should be placed in a rear-facing position in the car seat for optimal safety. Forward-facing car seats are used later, but infants should always be in a rear-facing car seat until they meet the age, weight, and height requirements for transitioning.
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