A nurse is caring for a client who is receiving intravenous magnesium sulfate for preeclampsia.
Which assessment finding would alert the nurse to suspect magnesium toxicity?
Rapid pulse.
Tingling in toes.
Cool skin temperature.
Absent deep tendon reflexes.
The Correct Answer is D
Choice A rationale
A rapid pulse is not typically associated with magnesium toxicity. Magnesium toxicity more commonly affects the nervous and muscular systems.
Choice B rationale
Tingling in toes can be a sign of early magnesium sulfate effects but not necessarily toxicity. It may indicate that the medication is starting to affect the nervous system.
Choice C rationale
Cool skin temperature is not a common sign of magnesium toxicity. Symptoms of magnesium toxicity are more related to neuromuscular and respiratory function.
Choice D rationale
Absent deep tendon reflexes are a key indicator of magnesium toxicity. This finding suggests that magnesium levels are high enough to depress neuromuscular function, requiring immediate medical intervention. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","G"]
Explanation
Choice A: Respiratory assessment
- The newborn is exhibiting signs of respiratory distress, such as mild grunting, nasal flaring, and intermittent retractions. These symptoms indicate potential respiratory issues that need immediate attention.
Choice B: Hemoglobin
- The newborn's hemoglobin level is 9 g/dL, which is below the normal range of 14 to 24 g/dL2. This indicates anemia, which can affect the baby's oxygen-carrying capacity and overall health.
Choice C: Serum glucose
- The newborn's serum glucose level is 38 mg/dL, which is below the normal range of 40 to 45 mg/dL2. Hypoglycemia in newborns can lead to serious complications if not addressed promptly.
Choice D: Heart rate
- The newborn's heart rate is 180 beats per minute, which is above the normal range for a newborn (normal range: 120-160 beats per minute)2. This tachycardia could be a response to stress or an underlying condition that needs evaluation.
Choice G: Hematocrit
- The newborn's hematocrit level is 35%, which is below the normal range of 44% to 64%2. This further supports the presence of anemia and the need for intervention2
Correct Answer is D
Explanation
Choice A rationale
Breast tenderness is considered a presumptive sign of pregnancy, as it can result from hormonal changes, but it is not definitive enough to confirm pregnancy.
Choice B rationale
Fetal heart tones detected by ultrasound are a positive sign of pregnancy. However, it is not a probable sign as it is definitive evidence of an existing pregnancy.
Choice C rationale
Fetal movement, often felt later in pregnancy, is a positive sign. It indicates an existing pregnancy but is not used to initially diagnose pregnancy.
Choice D rationale
A positive urine pregnancy test is a probable sign of pregnancy. It detects the presence of hCG (human chorionic gonadotropin), a hormone produced during pregnancy, and is a widely used indicator of probable pregnancy. .
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