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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. "There is no way to predict how long it will last in each individual client.": Although experiences can vary, there are well-established physiological patterns for urinary frequency in pregnancy. This response is vague and does not offer the client helpful information about what to expect.

B. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone.": Urinary frequency typically improves after the first trimester but returns near term due to increased uterine pressure. This response incorrectly links its persistence to bladder tone rather than uterine changes later in pregnancy.

C. "It occurs during the first trimester and near the end of the pregnancy.": Urinary frequency is common in early pregnancy due to hormonal effects and increased blood flow to the pelvis. It usually subsides in the second trimester but returns in the third trimester as the enlarging uterus presses on the bladder again.

D. "It's a minor inconvenience, which you should ignore.": Dismissing the symptom as a minor inconvenience overlooks the importance of client education. Clients should be encouraged to report concerning symptoms and receive supportive, informative responses from healthcare providers.

A. G3 TO P2 A1 L1 B. G2 T1 PO AO L2 C. G2 T1 PO A1 L2 D. G3 T1 PO A1 L1

Correct Answer is D

Explanation

A. G3 T0 P2 A1 L1: This option incorrectly states that the client has had two preterm births, which she has not. She has had one full-term birth and one abortion, making the parity count inaccurate in this case.

B. G2 T1 P0 A0 L2: This count underrepresents the client’s total pregnancies (G2 instead of G3) and indicates no abortions, which contradicts the elective abortion at 9 weeks. It also incorrectly lists two living children instead of one.

C. G2 T1 P0 A1 L2: While it correctly lists the term birth and abortion, it inaccurately lists two living children and indicates the client has had only two pregnancies instead of three, making the gravida count incorrect.

D. G3 T1 P0 A1 L1: The client has had three pregnancies (G3), one term birth (T1), no preterm births (P0), one abortion (A1), and one living child (L1). This option accurately reflects her obstetric history using the GTPAL system.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

A nurse is caring for a client who is at 23 weeks of gestation and has been unable to control her gestational diabetes mellitus with oral hypoglycemic therapy, diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

A nurse is educating a newly pregnant client about the stages of pregnancy. The client asks, "Which weeks are included in the first trimester?" The nurse correctly responds with which of the following?

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should recognize that this diagnosis means which of the following?

A nurse is caring for a pregnant client who is diagnosed with hyperemesis gravidarum. Which of the following interventions should the nurse prioritize for the pregnant client with hyperemesis gravidarum?

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?

A pregnant client at 28 weeks gestation reports experiencing leg discomfort and noticing bulging veins in her legs. The nurse explains that varicose veins are common during pregnancy. What is the primary physiological change during pregnancy that contributes to the development of varicose veins?