A nurse is caring for a client diagnosed with severe preeclampsia who is receiving intravenous magnesium sulfate for seizure prophylaxis. Which of the following findings should prompt the nurse to immediately intervene?

Respiratory rate of 8 breaths per minute

Urine output of 60 mL in the past two hours

Deep tendon reflexes of +2

Complaints of mild nausea and flushing

Answer and Explanation

The Correct Answer is A

A. Respiratory rate of 8 breaths per minute: A respiratory rate below 12 breaths per minute is a sign of magnesium toxicity. Magnesium sulfate can depress the central nervous system, and a rate of 8 indicates potential respiratory compromise, requiring immediate intervention and possible discontinuation of the infusion.

B. Urine output of 60 mL in the past two hours: Although slightly low, this output is not yet at the critical level of concern. Urine output should be ≥30 mL/hr to ensure magnesium is excreted effectively. Continued monitoring is needed, but it does not require immediate action.

C. Deep tendon reflexes of +2: A +2 reflex is considered normal and indicates that the client is not currently experiencing neuromuscular depression. Loss or absence of reflexes would be more concerning for magnesium toxicity.

D. Complaints of mild nausea and flushing: These are common and expected side effects of magnesium sulfate therapy. While they should be documented and monitored, they do not suggest toxicity and do not require urgent intervention.

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Correct Answer is D

Explanation

A. Congenital heart defects: While some environmental exposures may increase the risk of congenital anomalies, smoking is more closely linked with placental and growth complications rather than structural heart defects in the fetus.

B. Hearing loss: Hearing loss in newborns is commonly associated with infections, genetic conditions, or exposure to ototoxic medications. Maternal smoking has not been strongly linked to this outcome in pregnancy.

C. Type 1 diabetes mellitus: Type 1 diabetes is an autoimmune condition with a strong genetic component. Smoking during pregnancy does not contribute to the development of this chronic disease in infants.

D. Intrauterine growth restriction: Nicotine causes vasoconstriction and reduces placental perfusion, leading to decreased oxygen and nutrient delivery to the fetus. This significantly increases the risk of intrauterine growth restriction and low birth weight.

A. Station of the presenting part B. Pattern of contractions C. Rupture of the membranes D. Changes in the cervix

Correct Answer is D

Explanation

A. Station of the presenting part: Station refers to the position of the fetal presenting part in relation to the maternal ischial spines. While it can indicate fetal descent, it does not confirm the presence of active labor and may not change significantly early in the process.

B. Pattern of contractions: Contractions in true labor are typically regular and increase in intensity, but alone, they do not confirm true labor. False labor can also involve contractions that mimic this pattern, making them less reliable as the sole indicator.

C. Rupture of the membranes: Rupture of membranes can occur before true labor begins or even without labor. While it often precedes delivery, it is not definitive evidence that labor is active, especially if no cervical change is observed.

D. Changes in the cervix: Effacement and dilation of the cervix are the hallmark signs of true labor. These changes confirm that uterine contractions are causing physiological progress toward delivery, distinguishing true labor from false labor.

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A nurse is caring for a client diagnosed with severe preeclampsia who is receiving intravenous magnesium sulfate for seizure prophylaxis. Which of the following findings should prompt the nurse to immediately intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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